RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-00035
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20070608

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an activated National Guard E-4 (Signal Support Systems Specialist) medically separated for a right foot stress fracture.  The condition could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty (MOS).  
She was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB). The “stress fractures in the right cuboid and right calcaneus” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other condition was submitted by the MEB.  The Informal PEB (IPEB) adjudicated “chronic right foot and heel pain secondary to stress fracture of the right cuboid and calcaneus” as unfitting, rated 0% with likely application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The CI appealed to the Formal PEB (FPEB) that determined the CI’s present symptoms represent a natural progression of a condition that existed prior to enlistment. A Formal Reconsideration of the FPEB upheld the findings of the IPEB and the CI was rated for full motion at 0% and medically discharged.

CI CONTENTION:  Her conditions continue to worsen and negatively impact her daily activities.  Her complete submission is at Exhibit A. 

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 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 

Recon FPEB - Dated 20070515	VA* - (~7 Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Foot Stress Fracture	5099-5013	0%	Right Ankle Joint Capsulitis	5099-5009	0%	20080116	
			Stress Fracture, Right Foot Metatarsal	5284	0%		
Other Conditions x 0 (Not In Scope)	Other x 16 	
RATING:  0%	RATING:  40%	
*Derived from VA Rating Decision (VARD) dated 20080304 (most proximate to date of separation (DOS)).  

ANALYSIS SUMMARY:

Right Foot Stress Fracture Condition.  Within approximately 2 months of being activated in July 2006 the CI was placed on medical hold for assessment and treatment of problems that included pre-existing multiple joint pains considered to possibly be related to a history of osteoarthritis.  One month later, in mid-October 2006, she developed new severe pain in the right ankle area.  Radiologic evaluations discovered the existence of some mild reduction in bone density (osteopenia) and the presence of a stress fracture of two adjacent bones in the right foot (calcaneus and cuboid).  At a primary care clinic visit on 24 October 2006 (8 months prior to separation) the CI reported that the right foot pain had improved slightly.  She was noted to favor the right foot while walking.  An orthopedist on 14 November 2006 (7 months prior to separation) indicated that right foot pain began 3 weeks previously.  Activity modification had resulted in minimal improvement, and she still required an orthopedic boot to prevent pain while walking.  Physical examination showed a normal gait.  Right foot tenderness was present laterally but painful motion was absent.

At the MEB exam on 15 December 2006 (6 months prior to separation) the CI reported intermittent pain of knees, hips and ankles from osteoarthritis, but marked “No” for “Impaired use of arms, legs, hands or feet…swollen or painful joints… (and) knee trouble.”  The examiner marked “Normal” for “lower extremities… (and) feet.”  On the profiling section of the DD Form 2808, the examiner specified “stress fractures Rt (right) foot” as the disqualifying diagnosis.  At the narrative summary (NARSUM) evaluation on 4 January 2007 (5 months prior to separation) the CI’s chief complaint was “stress fractures of the right foot.”  The CI reported constant pain in the right foot of moderate severity which was exacerbated by impact activities, and she noted that the condition was slowly improving.  The examiner indicated there was also a history of generalized osteopenia (thin bones) and osteoarthritis involving the lower extremities.  Physical exam showed a normal gait.  There was no swelling or crepitus of any lower extremity joint; and “no restriction” of any joint range-of-motion (ROM).  The examiner stated that the stress fractures of the right cuboid and calcaneus bones were responsible for her physical restrictions and need for an MEB.  Ankle ROM performed on 12 January 2007 by physical therapy (PT) showed plantar flexion of 46 degrees (normal 45 degrees) and dorsiflexion of 2 degrees (normal 20 degrees).  Although “soft tissue pain” was noted to be present at the limits of motion, pain was not considered to be the cause of any limited motion.  The permanent physical profile on 18 January 2007 identified the medical condition as “stress fracture right foot/continued pain.”  

At the VA Compensation and Pension (C&P) exam on 16 January 2008 (7 months after separation), the CI reported she was currently employed as a cashier which required “95% standing and ambulatory activity compared to 5% sedentary activity.”  Her complaint was now bilateral lateral ankle pain.  The examiner noted that the right cuboid fracture was “managed through resolution” with an orthopedic boot.  Exam showed a normal gait.  There was no swelling, tenderness or painful motion related to the cuboid bone.  Mild tenderness was noted in an area of lateral ankle ligaments.  There was no limitation of motion.  The examiner stated that the cuboid fracture was resolved “without sequelae” and rendered a diagnosis of ankle capsulitis.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the condition at 0% coded analogously to 5013 (osteoporosis, with joint manifestations), citing “full motion” as a rationale.  The VA rated the right foot stress fracture (“right foot metatarsal”) at 0% using the 5284 code (foot injuries, other), but also assigned a 0% rating for right ankle joint capsulitis.  Regarding the VA’s approach, the Board noted that the calcaneus and cuboid bones are tarsal bones (not metatarsals), are adjacent to the ankle and located beneath the only area of (mild) ligamentous tenderness noted by the C&P examiner.  Therefore, assigning these two separate ratings constituted pyramiding, which IAW VASRD §4.14 is to be avoided.  Regarding the right foot stress fracture condition, Board members debated if the PEB’s coding pathway (which defaults to limitation of ankle motion, coded 5271) justified a 10% rating due to the limited ankle dorsiflexion noted on the Service PT exam; or if a 10% rating was justified IAW VASRD §4.59 (painful motion).  It was concluded that these pathways were supported by the evidence; therefore a 10% rating was warranted.

The Board finally considered if rating of lower extremity conditions other than the right foot stress fractures was warranted.  While the IPEB clearly specified that the unfitting condition was the right foot stress fractures, the FPEB’s DA Form 199 noted complaints of arthralgias of hips, knees and ankles, and indicated that underlying osteopenia was present.  After a careful assessment of the FPEB form, it was concluded that the unfitting condition was the right foot stress fractures, and other joint conditions were not included in the unfitting condition.  Although there was a lack of clarity by the FPEB, osteoporosis (or osteopenia) manifests symptomatically only if there is an associated fracture.  Accordingly, since the right foot was the only area of stress fracture, it was the only area “with joint manifestations” under the 5013 code.  Other arthralgias could therefore not be subsumed under this code.  However, even conceding that the FPEB intentionally bundled multiple joints into a single rating, there was a questionable basis for arguing that any of these joints were separately unfitting.  The well-established principle for fitness determinations is that they are performance-based.  Although the CI was placed on medical hold in part for multiple joint complaints, no joint except the right foot was profiled, and it was this profile to which the commander’s statement referred in commenting on duty performance.  The Board could not find evidence elsewhere in the STR that documented significant interference of hips, knees or left ankle pain with the performance of duties at the time of separation, nor were any physical findings documented in the STR which would logically be associated with significant disability.  By the time of the C&P exam the CI was engaged in employment that required continuous standing and walking.  It should also be noted that there is insufficient evidence in support of a compensable rating for any of these joints, even if they were conceded as unfitting, consistent with the VA’s determination of a 0% rating for the left ankle and non-service connection for the hips and knees.  After due deliberation, members agreed that the evidence does not support a conclusion that the functional impairment from bilateral hip pain, bilateral knee pain or left ankle pain was integral to the CI’s inability to perform her MOS, and accordingly cannot recommend a separate Service rating for them.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% for the right foot stress fracture 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 foot stress fracture condition, the Board unanimously recommends a disability rating of 10%, coded 5099-5013 IAW VASRD §4.71a.  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:  

CONDITION	VASRD CODE	RATING	
Right Foot Stress Fracture	5099-5013	10%	
RATING	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20131220, 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 XXXXXXXXXXXXXXXXXXX, AR20160000328 (PD201400035)

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 10% 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