RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXX	CASE:  PD-2013-01642
BRANCH OF SERVICE:  Army	BOARD DATE:  20150107
SEPARATION DATE:  20040525

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an activated Reserve SSG/E-6 (54B30/Chemical Operations Specialist) medically separated for left knee and bilateral foot pain.  These conditions could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty (MOS).  The profile allowed for an alternate physical fitness test to satisfy physical fitness standards.  She was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  The conditions, characterized as “degenerative joint disease of the left knee,” “metatarsal deformity,” and “callous/corn,” were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other conditions were submitted by the MEB.  The Informal PEB adjudicated the knee and foot conditions as unfitting, rated them as a single unfitting condition at 10%, citing application of the US Army Physical Disability Agency (USAPDA) pain policy.  The CI made no appeals and was medically separated.

CI CONTENTION:  “Chronic pain became severe for left knee and right knee which resulted into arthoscopic [sic] surgery and now both knees have been replaced.  Both feet still continues [sic] to have pain and have resulted with heel spurs.  Orthotics have been issued to no availed [sic] have helped pain.  Dued to the medical concerns of my feet and my left knee.  As explained in previous claims dued to the shift of weight from my left knee it had resulted in severe pain within my right knee.  I have submitted various claims for service connection of my right knee. My percentage for the total knee replacement of my Left Knee is at 30%.  My percentage for both feet is at 10%.”  

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 left knee and foot conditions are addressed below; the requested right knee condition was not identified by the PEB, and therefore is not 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 IPEB – Dated 20040402	VA - (2 Months Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Pain, Left Knee and Both Feet	5099-5003	10%	Recurrent Bilateral Plantar Tylomas…Warts and Callouses	7819-7806	10%	20040722	
			S/P Left Knee Arthroscopy…	5299-5257	10%	20040722	
Rating:  10%	Combined Rating:  20%	
Derived from VA Rating Decision (VARD) dated 20050105.

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 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, operating under a different set of laws.  The Board considers VA 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 left knee and bilateral foot conditions under a single disability rating, coded analogously to 5003.  Although the VA Schedule for Rating Disabilities (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 left knee and bilateral foot conditions is presented separately; with attendant recommendations regarding separate unfitness and separate rating if indicated.

Left Knee Condition.  In 2003, the CI aggravated a left knee injury dating back to 1984 when she fell.  Her X-rays were normal and she was referred to physical therapy for rehabilitation.  Her pain persisted and a magnetic resonance imaging of the left knee on 13 August 2003 documented disease of the outside (lateral) ligament, base of the knee (tibial plateau), and outside (lateral) meniscus (cartilage cushion in the knee).  On 17 September 2003, she underwent surgical repair of damage to the cartilage lining of the knee joint and the lateral meniscus.  Her knee was stable in all planes.  Post-operatively she continued rehabilitation, but had persistent (albeit improved) pain and limitation in motion.  She was issued a permanent L3 profile and referred for a MEB.  The narrative summary (NARSUM) was dated 23 January 2004, 4 months after surgery and 4 months prior to separation, she reported constant pain and limitations in activity.  Subjective instability or locking was not recorded.  On examination, her knee was stable, mild effusion was noted with palpable grinding (crepitus) on manipulation of the kneecap.  Flexion was reduced to 95 degrees with normal extension.  She used a cane for ambulation.  

At the VA Compensation and Pension (C&P) examination performed on 22 July 2004, 2 months after separation, the CI reported the use of a cane for lengthy walking.  She was a mental health counselor and had no occupational impairment from the knee.  On examination, the flexion was again reduced at 100 degrees, but the motion was painless, without crepitus and no effusion present.  Her knee was stable in all planes and the gait was normal without the use of the cane noted above.  Degenerative changes were present on X-ray.  The goniometric range-of-motion (ROM) evaluations in evidence which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below.

Left Knee ROM
(Degrees)	MEB ~ 4 Mo. Pre-Sep	VA C&P ~ 2 Mo. Post-Sep	
Flexion (140 Normal)	95	100	
Extension (0 Normal)	0	0	
Comment	Stable anterior and posterior	Motion pain free; stable knee	
§4.71a Rating	10%	10%	

The Board first considered if the knee was a separately unfitting condition.  The profile noted the CI could not run and walking was at own pace and distance, but allowed the “walk” as her alternate aerobic event for physical fitness testing.  The commander’s statement noted she was unable to perform the “very physically demanding” tasks of her MOS.  She had reduced ROM on multiple examinations and radiographic findings of degenerative changes.  The evidence supports the knee was a separately unfitting condition at separation.

The Board then directed its attention to its rating recommendation based on the above evidence.  The ROM was reduced, but not to a compensable level.  The lateral meniscus was repaired as was the cartilage lining of the joint.  The Board considered the codes available for the knee and determined that 5259 best fit the clinical picture and supported a 10% rating.  The Board found no route to a higher rating for the knee absent instability and compensable ROM loss.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% coded 5259 for the left knee condition.

Bilateral Foot Condition. The CI was first treated for bilateral plantar warts (a viral infection causing a painful build-up of skin tissue) in 1987.  This was apparently successful and the records fall silent for the feet until 2002 when she is evaluated for bilateral callouses, right more symptomatic than the left.  She did not respond adequately to conservative treatment and was found to have an abnormally long second metatarsal (long bone in the foot next to that of the big toe).  This was surgically treated on 11 June 2003.  Although her symptoms improved, she continued to have pain despite continued post-surgical management including debridement, injections, orthotics, and wearing a “shoe for comfort.”  At the MEB physical examination on 24 November 2003, she was noted to have pain over the 2nd and 3rd metatarsals bilaterally.  The podiatry NARSUM was dated 26 January 2004, 4 months prior to separation.  On examination, she was noted to have second metatarsal bones longer than normal bilaterally, but only the right had been treated with surgery.  On examination, a callous was noted over the head (towards the toes) of the right second metatarsal which was mildly tender.  No comment was made on the left foot.  She was not thought to meet retention standards although her long term prognosis was fair to good.  The Board observed that the podiatry treatment notes in the months leading up to separation primarily addressed the right foot.  The VA C&P examination noted a 1/2 inch “plantar wart” over the right 2nd metatarsal head and a similar “plantar wart” which was1/4 inch over the left second metatarsal head.  The foot and ankle were otherwise unremarkable.  Tenderness was not documented and the gait was recorded as normal.

The Board first considered if the bilateral foot condition was separately unfitting.  The profile noted the CI could not run.  The relative contribution between the knee and foot conditions was not determined.  She had improved, but had persistent symptoms after surgery and was unable to meet duty requirements despite a shoe of comfort and orthotics.  The commander’s statement noted she was unable to perform the “very physically demanding” tasks of her MOS.  The Board considered if each foot was separately unfitting.  It noted the normal gait and absence of tenderness on the VA examination and the fact that the treatment notes for the feet were primarily for the right foot.  The evidence did not support a finding that the left foot was separately unfitting at separation independent of the right foot.  
The Board then directed its attention to its rating recommendation based on the above evidence.  The PEB combined the knee and feet into a single condition citing the pain policy.  The VA rated the feet at 10% using a code for dermatitis (7806) and skin neoplasms (7819).  The Board determined that neither code accurately represented the clinical findings which were of callous formation secondary to an abnormally long second metatarsal bilaterally, the right side more symptomatic and treated with surgery.  The Board determined that the code 5279 (metatarsalgia) best fit the clinical picture and supported a 10% rating for either bilateral or unilateral disease.  The Board found no route to a higher rating for the foot condition.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% coded 5279 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 both the knee and bilateral foot condition was operant in this case and the conditions were adjudicated independently of that policy.  In the matter of the left knee condition, the Board unanimously recommends a disability rating of 10%, coded 5259 IAW VASRD §4.71a.  In the matter of the right foot condition, the Board unanimously recommends a disability rating of 10%, coded 5279 IAW VASRD §4.71a.  The left foot was determined to not be separately 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	
Chronic Pain, Left Knee	5259	10%	
Metatarsalgia, Right Foot	5279	10%	
COMBINED (w/ BLF)	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20130927, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

				
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 XXXXXXXXXXXXXXXXX, AR20150007046 (PD201301642)

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 rating to 20% without 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:

CF: 
(  ) DoD PDBR
(  ) DVA