RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-00109
BRANCH OF SERVICE:  Army	BOARD DATE: 20150220
SEPARATION DATE:  20071228

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-5, (Health Care Specialist) medically separated for chronic bilateral foot pain.  The condition could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty or satisfy physical fitness standards.  She was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  The bilateral foot pain condition, characterized as “bilateral tarsal tunnel syndrome and right ankle and subtalar instability” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also identified and forwarded four other conditions as meeting retention standards (seasonal allergies, cystic acne, constipation, and hypothyroidism).  The Informal PEB (IPEB) adjudicated “chronic bilateral foot pain” as unfitting, rated 20%. The remaining conditions were determined to be not unfitting. The CI made no appeals and was medically separated.

CI CONTENTION:  “I was later diagnosed with PTSD and the severity of Hashimoto’s Disease and Axonal neuropathy diagnoses.”

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:

Service IPEB – Dated 20071205	VA - (6 Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Foot Pain 	8799-8725	20%*	Plantar Fasciitis with Tarsal Tunnel Syndrome Left Foot	5010-5284	10%	20080515	
			Plantar Fasciitis with Tarsal Tunnel Syndrome Right Foot	5284	10%	20080515	
Hypothyroidism	Not Unfit	Hypothyroidism	7903	10%	20080812	
Other x 3 (Not in Scope)	Other x 2 (Not in Scope)		
Combined:  20%	Combined:  30%	
Derived from VA Rating Decision (VARD) dated 20080715 (most proximate to date of separation [DOS]).
*The PEB rated each foot condition 10% with application of the bilateral factor.

ANALYSIS SUMMARY:

Bilateral Foot Pain Condition.  According to service treatment records and the MEB narrative summary (NARSUM), the CI experienced recurring problems with bilateral foot pain since initial military training in 2001.  She experienced worsened pain in 2004 associated with a stress fracture and neuralgia.  Although she recovered there was recurrent pain due to plantar fasciitis.  In February 2006, she underwent right foot tarsal tunnel release surgery for a pinched nerve (tarsal tunnel syndrome) with good result and return to full activities.  She developed recurrent bilateral foot pain due to bilateral tarsal tunnel syndrome (confirmed by electrodiagnostic studies).  At the time of the MEB NARSUM examination on 29 October 2007, there was tenderness over both tarsal tunnel regions of the foot.  There was “slightly increased translation and anterior drawer test” with normal strength of the right ankle.  At the time of the VA general medical Compensation and Pension (C&P) examination on 12 May 2008, 6 months after separation, the CI reported persistent foot pain aggravated by running and prolonged walking.  Discomfort was most notable in the morning and then again in the evening.  Her symptoms were improved by use of orthotics.  On examination the gait was normal and foot and ankle range-of-motion was normal.  There was tenderness at the instep of both feet and tapping on the right tarsal tunnel region produced discomfort.  At the VA foot C&P examination, the CI reported constant foot pain but was able to perform her work as a medical office assistant.  On examination there was no swelling, heat, redness, tenderness or deformity (including deformity of the hindfoot, midfoot, or forefoot, hammertoe, high arch, or valgus or varus deformity).  There was mild bilateral pes planus but the Achilles tendons were well aligned and non-tender.  There was no significant callus formation or evidence of unequal shoe wear.  The CI rose and stood from a chair normal, and the gait was normal including walking on toes and heels.  The CI was able to hop on either foot and able to squat normally.  Recent X-rays of both feet were normal.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral foot pain (diagnosed as tarsal tunnel syndrome) 20% (coded 8799-8725; posterior tibial nerve neuralgia); each foot rated 10% with application of the bilateral factor.  The VA rated each foot (plantar fasciitis with tarsal tunnel syndrome) 10% (coded 5284; other foot injuries, moderate).  All members agreed, the evidence of the MEB and VA C&P examinations did not support a rating higher than the 10% for each foot adjudicated by both the PEB and the VA proximate to the time of separation.  The mild examination findings and the normal gait did not more nearly approximate moderately severe under diagnostic code 5284, or severe under code 8725.  The Board noted the PEB cited right ankle instability in its fitness and rating decision for the bilateral foot pain condition.  The Board however did not find evidence that indicated the ankle instability, characterized as slight by the MEB examiner, was separately unfitting for military service when considered alone.  Further, any impairment associated with the slight instability of the right ankle could not be separated from that from the foot pain and tarsal tunnel and is subsumed in the rating for the right foot pain.  In accordance with VASRD §4.14 (avoidance of pyramiding), two ratings for the same impairment are prohibited.  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 bilateral foot pain condition.

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that the hypothyroidism was not unfitting.  The Board’s threshold for countering PEB fitness determinations is “preponderance of evidence,” but remains adherent to the DoDI 6040.44 “fair and equitable” standard.  The CI complained of symptoms suggestive of hypothyroidism including hair loss, constipation and weight gain.  There was no obvious enlargement of the thyroid gland or palpable abnormalities on examination.  Laboratory testing disclosed a slightly elevated thyroid stimulating hormone level consistent with sub-clinical hypothyroidism.  She was begun on thyroid hormone replacement therapy.  At an appointment on 11 December 2007, she reported improved symptoms.  At the time of the VA C&P examination on 9 May 2008, the examiner noted that since starting medication symptoms of fatigue and hair loss were improving and she did not complain of significant fatigue.  On examination, the thyroid gland was normal.  Laboratory testing in March 2008 showed a normal thyroid stimulating hormone level.  The hypothyroid condition was not profiled or implicated in the commander’s statement and was not judged to fail retention standards.  The condition was reviewed and considered by the Board.  There was no performance based evidence from the record that this condition significantly interfered with satisfactory duty performance.  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 the any of the hypothyroid condition and so no additional disability rating is recommended.

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.  In the matter of the bilateral foot pain condition, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended hypothyroid condition, the Board unanimously recommends no change from the PEB determination as not unfitting.  There were no other conditions within the Board’s scope of review for consideration.

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

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20131223, 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 XXXXXXXXXXXXXXXXXXXXXX, AR20150019009 (PD201400109)

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:

Enclosure

CF: 
(  ) DoD PDBR
(  ) DVA