RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-00288
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20070209

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E4, Tracked Vehicle Mechanic, medically for “low back pain” and “bilateral foot pain.”  The low back pain was rated 10% and the bilateral foot pain was determined to have existed prior to service (EPTS) and not rated.

CI CONTENTION:  The CI contends his conditions continue to worsen and negatively impact his daily activities.  The CI’s complete submission is at Exhibit A.  

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44.  It is limited to those conditions determined by the Physical Evaluation Board (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 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 PEB - 20061220	VARD - 20070717	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain…	5237	10%	Degenerative Disc Disease of the Lumbar Spine L5-S1	5243	10%	20070416	
Bilateral Painful Feet From Pes Planus Deformities…	5299-5276	---%	Bilateral Pes Planus	5276	0%		
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Low Back Condition.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the low back pain (LBP) condition began approximately 2 years prior to referral for MEB.  An X-ray showed L5-S1 degenerative disc disease (DDD) and an MRI showed L5-S1 disc degeneration and desiccation.  The NARSUM, 3 months before separation, recorded that the CI first noted back pain approximately 20 months prior.  He exacerbated his LBP 6 months earlier when he lifted a several hundred pound object without assistance.  The CI heard popping in his back and experienced immediate back pain.  He dropped the object, had only minor residual back pain and did not go to sick call for approximately 4 weeks.  While his back pain improved, he failed conservative management which included activity modification, back school, physical therapy (PT), and medication.  The CI complained of chronic 5/10 LBP with exacerbations to 8/10.  Pain was worsened by activity, bending, repetitive motion, prolonged walking, running, prolonged driving, and load bearing and relieved by rest and inactivity.  With prolonged walking, sharp pain would shoot down his left leg to his knee.  The CI denied bowel or bladder incontinence but complained of trouble sleeping secondary to his back pain.  The active medication was a muscle relaxant (Flexeril).  The physical examination documented the CI was able to toe and heel walk, but heel walking aggravated his LBP.  The spine examination revealed lumbar paravertebral muscle tenderness and tightness.  The straight leg raise (SLR) tests (assess nerve root compression by a herniated disc) caused LBP, but not radicular (nerve root) pain.  The back range-of-motion (ROM) examination was incomplete and recorded in a non-standard fashion.  It documented flexion of 10-15 (90 normal) degrees, extension of 0 (30) degrees, and bilateral lateral flexion of 10-15 %.  Sensation and pulses were normal, deep tendon reflexes (DTRs) were symmetric, and there was no evidence of muscle atrophy (wasting).  The examiner recounted the findings of the X-ray and MRI.  The impression listed LBP with non-radicular pain involving the lumbosacral spine.  Active thoracolumbar ROM values measured by PT for the MEB are listed in the chart.  The PT physical examination documented no antalgic (assuming a gait or posture to lessen pain) gait.  There were psychogenic, or nonorganic, manifestations of pain with positive SLR tests supine but not sitting, and simulated rotation/loading.  Sensation was normal and there were no muscle spasms.  Patellar reflexes were asymmetric, Achilles reflexes were symmetric, and pathologic reflexes were absent.  The therapist documented that the reason for limitation was pain and the CI was able to achieve near-normal to supra-normal passive ROM.  The therapist opined “Believe all motions within 5% end of physiological range except extension ….”  In the Compensation and Pension (C&P) examination, the CI reported wrenching his back lifting a 500-pound tow bar.  He complained of constant 4/10 LBP without flares.  The CI had no incapacitating episodes, or missed work, in the past 12 months due to this condition.  The active medication was an analgesic (Tylenol) as needed.  The physical examination documented a normal gait with no assistive devices.  The spine examination revealed lower lumbar spine tenderness.  The SLR tests were negative.  Lumbar spine repetitive ROM was limited by pain, but not weakness, fatigability, incoordination, or lack of endurance.  Strength, sensation, and DTRs were normal.  An X-ray showed likely pars (bone segments joining vertebral facet joints) defects bilaterally at L5.  The diagnosis listed mechanical LBP with likely pars defects at L5.

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating under the 5237 code (lumbosacral or cervical strain), citing chronic LBP, onset after lifting strain, mild single-level DDD by imaging, pain-limited ROM, and paraspinal muscle tenderness.  The VA assigned a 10% rating under the 5243 code (intervertebral disc syndrome) based on the VA C&P examination 2 months after separation, citing chronic LBP, DDD by imaging, ROM, pain on ROM, no incapacitating episodes, no radicular symptoms, no tenderness, no muscle spasms, no abnormal spinal contour, no abnormal gait, and no significant limitation due to pain, weakness, fatigue, lack of endurance, or incoordination on repetitive ROM.  The ROM values in the NARSUM examination, 2 months before separation, were incomplete and recorded in a non-standard fashion.  The ROM values in the proximate general medical and H&P (DD Form 2808) examinations did not attain the minimum 10% rating based upon the general rating formula for diseases and injuries of the spine.  The higher 10% rating would require flexion of greater than 60 degrees but not greater than 85 degrees; or a combined ROM of greater than 120 degrees but not greater than 235 degrees of the thoracolumbar spine.  The ROM values in the C&P examination were consistent with the 10% rating.  The ROM values in the PT for MEB examination were consistent with the 40% rating.  Three of the four proximate examinations reflected normal, or near normal (10%) ROM values.  The PT for MEB ROM measurements reflected limitations in the context of a pain exacerbation.  Pain was documented as the reason for limitation of motion and the therapist opined “Believe all motions within 5% end of physiological range except extension…”  The Board assigned more probative value to the post-exacerbation C&P examination, 2 months after separation, as accurately reflecting the CI’s condition at the time of separation.  There was no documentation of incapacitating episodes, or evidence of ratable peripheral nerve impairment, which would provide for additional or higher rating.  The Board agreed a 10% rating was supported based on VASRD §4.40 (functional loss) or §4.59 (painful motion).  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 low back condition.

Bilateral Pes Planus EPTS Condition.  The PEB combined the right and left pes planus conditions as a single unfitting condition coded 5299-5276 (flatfoot, acquired) and determined it was EPTS.  The approach by the PEB not uncommonly reflected its judgment that the constellation of conditions was unfitting, and there was no need for separate fitness adjudications or implied adjudication that each condition was separately unfitting.  The Board’s initial charge in this case was therefore directed at determining if the PEB’s approach of combining conditions under a single rating was justified in lieu of separate ratings.  When considering a separate rating for each condition, the Board considers each bundled condition to be reasonably justified as separately unfitting unless a preponderance of evidence indicates the condition would not cause the member to be referred into the Disability Evaluation System or be found unfit because of physical disability.  When the Board recommends separate fitness recommendations in this circumstance, its recommendations may not produce a lower combined rating than that of the PEB.  The evidence for the right and left pes planus conditions are presented together, with attendant recommendations regarding separate unfitness and rating in the rating discussion.

According to the STR and NARSUM, the bilateral pes planus existed at the MEPS enlistment physical.  Serial X-rays showed pes planus with otherwise normal anatomic alignment, joints spaces, and soft tissues with no fractures or subluxations (incomplete or partial dislocations).  A clinic examiner recounted the findings of the foot X-rays.  The assessment listed pes planus and orthotic inserts were ordered.  A single left foot weight bearing X-ray showed degenerative changes at the talonavicular joint.  At a podiatry encounter, the CI complained of a history of bilateral pes planus aggravated by prolonged ambulation.  He had been on low impact profiles for 4 months and was being treated with nonsteroidal anti-inflammatory drugs (NSAIDs), orthotics, and night splints.  The CI related he had gained 20 pounds lifting heavy weights in the gym.  The bilateral foot examination revealed decreased medial longitudinal arch height and bulging along the medial talonavicular joint with weight-bearing.  There was no erythema (redness), edema (excess tissue fluid swelling), or ecchymosis (bruising).  There was full ROM about the subtalar joints bilaterally.  The podiatrist recounted the findings of the weight-bearing X-rays which demonstrated pes planus.  The assessment listed pes planus congenital (inborn physical abnormality or disease) foot deformity.  The Report of Medical Examination for the MEB (DD Form 2808) documented symptomatic flexible pes planus.  The NARSUM recorded that the CI noted gradual onset of foot pain approximately one year earlier.  He was treated by podiatry with activity modification, a stretching program, custom orthotics, and night splints.  The CI complained of chronic 5/10 pain with standing and 6-7/10 pain with walking (>1/2 mile).  Pain was exacerbated by standing, walking, running, and impact activities and relieved by nonweight-bearing, rest, and inactivity.  Foot pain did not interfere with sleep.  The physical examination documented the CI was able to toe and heel walk.  The feet appeared normal when not weight bearing, but the arches flattened significantly with standing.  The bilateral foot examination revealed normal motion and flexibility with no tenderness.  The ROM examination revealed full plantarflexion and dorsiflexion.  Sensation and pulses were normal, DTRs were symmetric, and there was no evidence of muscle atrophy.  The examiner recounted the findings of the X-rays.  The impression listed bilateral pes planus.  In the C&P examination, the CI reported his feet began to hurt after prolonged running and standing 2 years prior.  The active medication was Tylenol as needed.  The physical examination documented a normal gait with no assistive devices.  The CI was able to stand on his toes and heels without difficulty.  The bilateral foot examination revealed mild flattening of the plantar arches with no abnormal weight bearing, excessive callus formation, or uneven shoe wear.  The Achilles tendons were midline to the ankles.  Bilateral ankle ROM was dorsiflexion of 20 (20) and plantarflexion of 40 (45) degrees.  Bilateral foot repetitive ROM was not limited by pain, weakness, fatigability, incoordination, or lack of endurance.  Strength, sensation, and DTRs were normal.  The X-rays showed mild loss of the plantar arches with no fracture or subluxation.  The diagnosis listed mild bilateral pes planus.

The PEB determined the bilateral pes planus condition existed prior to service (EPTS) based on the MEPS enlistment physical.  The Board found no evidence to indicate this was not correct.  The Board next considered whether or not there was evidence of service aggravation.  A presumption of service aggravation may only be overcome by a preponderance of competent medical evidence and accepted medical principles that the natural progression of a pre-existing condition was clearly unaltered by any consequence of military service. 

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB did not assign a rating under an analogous 5276 code (acquired flatfoot), citing bilateral painful feet from pes planus deformities noted on entry examination, feet had been symptomatic since shortly after entry, normal imaging, feet improved with rest and hurt with marching, and the symptoms represented the natural course of a pre-existing condition without permanent service aggravation.  The VA assigned a 0% rating under the 5276 code (acquired flatfoot) based on the VA C&P examination 2 months after separation.  The VA cited no evidence of pes planus when entered service, diagnosis of pes planus during service, provided arch inserts, examination showed mild pes planus, no evidence of abnormal weight bearing, no bowing of tendo Achilles, no pain on manipulation, no excessive callus formation, no uneven shoe wear, and no functional limitation due to pain, weakness, fatigue, lack of endurance, or incoordination.  The preexisting pes planus was characterized as mild and asymptomatic per the MEPS enlistment physical.  Board members agreed the condition did not exceed the 0% rating under 5276 (mild; symptoms relieved by built-up shoe or arch support).  Members debated if 0% was warranted for the bilateral feet or if application of §4.40 or §4.59 justified a 10% ratings.  The Board agreed a 10% rating was supported based on VASRD §4.40 (functional loss) or §4.59 (painful motion).   The Board carefully considered the option of rating each foot separately, noting that the PEB and VA rated both feet together.  The Board concluded that the evidence did not provide sufficient grounds for recommending separate foot disability ratings in this case, and that a bilateral rating of 10%, coded 5276, is a good analogy to both the pathology and disability.  After due deliberation, considering all of the evidence the Board concluded the pes planus condition was permanently aggravated by service and recommends a disability rating of 10% (coded 5276).

BOARD FINDINGS:  In the matter of the low back condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended pes planus EPTS condition, the Board unanimously concluded there was permanent service aggravation and recommends a disability rating of 10%, coded 5276 IAW VASRD §4.71a.  There were no other conditions within the Board’s scope of review for consideration.  The Board recommends that the CI’s prior determination be modified as follows, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	RATING	
Chronic Low Back Pain	5237	10%	
Bilateral Painful Feet From Pes Planus Deformities	5276	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140107, 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 XXXXXXXXXXXXXXXXXX, AR20160006628 (PD201400288)

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, accept the Board’s recommendation to modify the individual’s disability rating to 20% without re-characterization 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