RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	    CASE:  PD-2014-00510
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20070623

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E-5, Military Police, medically separated for “left foot adult acquired flat foot and posterior tendonitis” with a disability rating of 0%.  

CI CONTENTION:  The CI contends she was medically cleared to join the Army and her injuries were the result of training, physical training and mission execution.  The applicant’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 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 - 20070326	VARD - 20080310	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Foot Pain	5024	0%	Chronic Left Foot Pain	5284	10%	20070806	
Left Knee Pain	5003	--%	Chronic Left Knee Pain 	5257	NSC	20070806	
Right Wrist Pain	5099-5003	--%	Chronic Right Wrist Pain	5215	NSC	20070806	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Left Foot Pain.  In May 2005, this CI injured her left foot, and started having left foot pain.  She was treated with physical therapy (PT), medication, orthotics, and other conservative measures.  In spite of all treatment efforts, her foot pain persisted and an MEB was initiated.  The MEB physical examination (PE) was on 6 December 2006.  PE of her left foot showed pes planus deformity (flatfoot).  There was tenderness to palpation (TTP) along the posterior tibial tendon, but no TTP laterally.  The left foot was neurovascularly intact.  The MEB narrative summary (NARSUM) diagnosis for the left foot was: “Adult acquired flat foot.”
On 27 April 2007, the CI had a VA Compensation and Pension (C&P) General medical exam.  She reported that her left foot hurt at rest.  Walking and standing made it worse.  She had difficulty with biking and with driving.  She was able to do stairs if she went slowly.  On PE, she was in no acute distress.  A specific PE of the left foot revealed no evidence of redness, swelling, or crepitus to palpation.  There was some TTP, and some pain with motion.  Sensation was intact.  The foot arch was described as “mild pes planus.”  The C&P examiner’s diagnosis for the left foot was: “chronic posterior tibial tendonitis.”

As noted above, the CI was found unfit for military duty, and was medically separated from service on 23 June 2007.  Six weeks later, on 6 August 2007, she had another VA C&P exam.  She reported that she could walk a mile, before she needed to sit down.  She could stand for about 15 minutes before her left foot started to hurt.  She was working as a laboratory technician, and was planning on finishing school.  As far as activities of daily living (ADLs), her medical problems did not affect her ADLs.  She could feed herself, dress herself, go to the bathroom by herself, and shower by herself.  On PE, her posture and gait were normal.  On neurological exam, muscle power was normal.  Sensation and reflexes were intact.  A specific PE of the left foot was not recorded.

The Board carefully reviewed all available information, and directed attention to its rating recommendation based on the evidence.  The Army PEB and the VA chose different coding and rating options for the left foot pain.  The PEB used VASRD code 5024 (Tenosynovitis), and rated it 0%.  The VA coded it 5284 (Foot injury), and assigned a disability rating of 10% (moderate).  Following a thorough examination of the evidence, the Board determined that the CI’s chronic left foot condition was best described as “moderate.”  There was insufficient evidence in the record to support describing her foot condition as “moderately severe” or “severe.”  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 unfitting left foot condition.  It should be coded 5284, and IAW VASRD §4.71a, meets criteria for the 10% rating level (moderate). 

Left Knee Pain.  On 13 June 2000, before entering active duty, the CI suffered multiple injuries in a motor vehicle accident (MVA).  In addition to her other injuries, both knees were injured in the MVA.  In May 2001, she had arthroscopic surgery on the left knee. Six months later, in November 2001, she was seen by Orthopedics and it was determined that she had “excellent results” from her left knee surgery.  She entered active duty on 9 November 2001.  During basic training and Advanced Individualized Training (AIT), she had problems with knee pain.

In June 2003, in response to increased running, she complained of bilateral knee pain.  She was treated with medications and PT.  In October 2003, she was recommended for a permanent P-2 profile, due to bilateral knee pain.  On 7 April 2006, the CI was seen by Orthopedics.  The examiner’s diagnostic assessment was bilateral retropatellar pain syndrome (RPPS), with documented chondromalacia left knee.

In December 2006, PE of the left knee showed some TTP anteriorly over the left patellar tendon.  There was no medial or lateral joint line tenderness.  All tests for ligamentous laxity were negative.  Neurovascular examination was intact.

At the 27 April 2007 C&P exam, she reported problems with walking, stairclimbing, squatting, and prolonged standing.  On PE, she was in no acute distress.  PE of the left knee showed no effusion, swelling, redness, or crepitus to palpation.  There was some TTP of the left knee.  The joint was not unstable, but there was a little more medio-lateral play and more give, than on the right.  Left knee ROM was normal and with repetitive motion there was pain, but no weakness or fatigability.

Once again, the Board directed attention to its recommendation based on the evidence.  The Army PEB adjudicated the left knee pain as “existed prior to service (EPTS).”  On DA Form 199, the PEB wrote: “There is no evidence of permanent service aggravation.”  Following a thorough review of the record, the Board determined that there was no history of specific trauma or acute injury to the left knee, during the period of active duty.  In December 2006, x-rays showed diffuse narrowing of the joint space, in both lateral and medial compartments.  These findings were consistent with probable early arthritis.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board found (by majority decision) insufficient cause to recommend a change in the PEB adjudication of the left knee condition.  It was indeed EPTS, and there was insufficient evidence of permanent service aggravation beyond natural progression.    

Right Wrist Pain.  During the June 2000 MVA, the CI injured her right wrist.  She was told that it was not fractured.  She underwent occupational therapy (OT), which caused improvement in her symptoms.  In June 2003, the CI fell onto her hands, and once again started having problems with her right wrist.  The wrist symptoms were also attributed to an increase in physical training, especially push-ups.  In August 2006, magnetic resonance imaging (MRI) of the right wrist was normal.  In December 2006, the CI’s wrist was evaluated by an orthopedic surgeon.  PE of the right wrist showed mild tenderness to palpation, especially dorsally.  Tests for instability, or other seriously disabling joint abnormality were negative. The examiner’s diagnostic assessment was: Right wrist pain, due to tendonitis.

At the 27 April 2007 C&P exam, she reported “pins and needles” when she lifted heavy objects.  She felt that the wrist was unstable and weak.  Driving was ok, unless she gripped too long, and that would aggravate her wrist.  On PE, she was in no acute distress.  PE of the right wrist showed no swelling, redness, or crepitus to palpation.  There was some TTP of the right wrist, but no muscle atrophy.  Right wrist ROM was measured.  Active palmar flexion was 80 degrees, and active dorsiflexion (aka extension) was 24 degrees.  With repetitive motion there was pain, but no weakness or fatigability.

The Board again directed attention to a recommendation based on the evidence.  The Army PEB adjudicated the right wrist pain as EPTS.  On DA Form 199, the PEB wrote “There is no evidence of permanent service aggravation.  This is a natural progression of an EPTS condition.”  Following a thorough review of the record, the Board determined that there was insufficient evidence of permanent service aggravation, over and above natural progression of the pre-existing right wrist condition.

After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board majority found insufficient cause to recommend a change in the PEB adjudication of the right wrist condition.  It was indeed EPTS, and there was insufficient evidence of permanent service aggravation beyond natural progression.      

BOARD FINDINGS:  In the matter of the left foot condition, the Board unanimously recommends a disability rating of 10%, coded 5284, IAW VASRD §4.71a.  In the matter of the left knee condition, the Board majority recommends no change in the PEB adjudication as EPTS, without permanent service aggravation.  In the matter of the right wrist condition, the Board majority recommends no change in the PEB adjudication as EPTS, without permanent service aggravation.  The single voter for dissent did not elect to submit a minority opinion.  There were no other conditions within the Board’s scope of review for consideration.  The Board, therefore, 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	
Left Foot, With Posterior Tibial Tendonitis	5284	10%	
Early Arthritis and Retropatellar Pain Syndrome, Left Knee	5003	---%	
Right Wrist Pain	5099-5003	---%	
COMBINED	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140112, with attachments
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, AR20160005539 (PD201400510)

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 10% 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