RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-00599
BRANCH OF SERVICE:  NAVY	BOARD DATE:  20150225
Separation Date:  20060907

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (Central Files Administrative Clerk) medically separated for a bilateral foot condition.  The bilateral foot condition could not be adequately rehabilitated to meet the physical requirements of her rating or satisfy physical fitness standards.  The CI was placed on limited duty and referred for a Medical Evaluation Board (MEB).  The bilateral foot condition, characterized as “planovalgus bilateral feet s/p (status post) SBA (Subtalar Brancheau Arthroeisis) implants,” was the only condition forwarded to the Physical Evaluation Board (PEB) IAW SECNAVINST 1850.4E.  The Informal PEB adjudicated “planovalgus feet, bilateral, s/p SBA implants” as unfitting, rated 10%, with application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The CI non-concurred and requested a reconsideration PEB.  The reconsideration PEB upheld the PEB’s findings and the CI was separated.

CI CONTENTION:  The CI writes: “I feel that it should be changed because it affected and still affects my quality of life and I am still having lots of pain and issues with it.  Also, because it only considered left foot and should have included both feet because while on active duty I had bilateral feet operations.  It should have also included anxiety and depression because I was being treated for it while on active duty.”

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:

Service Recon IPEB – Dated 20060519	VA - (8 Mos. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Planovalgus Feet, Bilateral, s/p SBA Implants	5299-5284	10%	Planovalgus Left Foot s/p Surgery	5284	10%	20070501	
			Planovalgus Right Foot s/p Surgery	5284	0%	20070501	
Other x 0 (Not in Scope)	Other x 8	20070501	
Combined:  10%	Combined:  50%	
Derived from VA Rating Decision (VARD) dated 20070829 (most proximate to date of separation [DOS])

ANALYSIS SUMMARY:  The Board, IAW VASRD §4.7 (higher of two evaluations), must consider separate ratings for PEB bilateral joint adjudications; although, separate fitness assessments must justify each disability rating.  It remains, however, that both feet were considered to fail retention standards; both were implicated by the narrative summary (NARSUM); and, both caused duty limitation.  Since the disability attendant to only the left or right foot cannot be isolated by the clinical evidence, or extricated from the fitness implications of the bilateral limitations; members agreed that the left and right foot conditions should be likewise conceded as separately unfitting and that coding and rating features were logically identical.

Planovalgus Feet, Bilateral, s/p SBA Implants Condition.  The CI first sprained her left ankle in January 2004 with symptoms of pain, mild laxity, and tenderness to palpation.  She was followed by physical therapy (PT) on a monthly basis for left ankle strengthening.  On 22 September 2005, the podiatrist documented bilateral foot pain, with physical exam findings of tenderness to sinus taris both feet, mild foot and ankle edema and severe pes planus on weight bearing.  The bilateral feet X-ray showed a bilateral pes planus deformity.  The Family Practitioner noted ongoing pain in the left instep, greater than the right instep, worse with running and prolonged standing.  The pain was not resolved after Podiatry and a trial with inserts.  There were physical exam findings of moderate to severe pronation, left greater than right, and minimal left instep tenderness to palpation (TTP) extending to the medial malleolus.  The CI underwent a bilateral SBA implant surgery on 3 November 2005.  X-rays of both feet showed appropriate post-operative results.  The Podiatrist documented that the CI reported that although she was not experiencing pain from her flat feet, she felt that she was walking on the outside part of her feet.  There were physical exam findings of bilateral TTP and healed incision sites and she was given heel wedge inserts for her shoes.  She was seen again by Podiatry a week later for severe burning and moderate pain at the incision sites and an inability to tolerate wearing her boots.  There were physical exam findings of palpable scar tissue and edema.  The examiner ordered a bilateral cortisone injection to relieve the pain.  The CI reported no long-term benefit of the injections as there was only a week of symptom relief for the left foot and 2 days of symptom relief for the right foot.  The examiner referred the CI to PT for evaluation and treatment.  The PT documented pain, decreased range-of-motion (ROM), decreased flexibility and decreased proprioception (an inability to single leg heel raise secondary to weakness).  A bilateral foot X-ray demonstrated that the bilateral orthopedic implants between the talus and calcaneus remained stable.  The Podiatrist noted TTP with ROM of the postero-lateral aspect of both ankles, right greater than left.  She requested removal of the SBA implants.

The MEB NARSUM exam approximately 5 months prior to separation documented complaints of bilateral foot pain with no post-operative improvement in the physical appearance of both feet, and the flat foot deformity was essentially unchanged.  The examiner opined that the bilateral foot condition was deemed “Existed Prior to Service;” however, the condition was service-aggravated.  The MEB NARSUM physical exam findings are summarized in the chart below.  Removal of the left foot SBA implant was performed on 19 June 2006, which resulted in a decrease in the left foot pain.
The VA Compensation and Pension (C&P) exam approximately 8 months after separation documented that the CI had bilateral functional loss of 90% with sharp, aching burning pain rated at 10/10 made worse with walking and standing.  The VA C&P physical exam findings are summarized in the chart below.

There were ROM evaluations in evidence, with documentation of additional ratable criteria, which the Board weighed in arriving at its rating recommendation; as summarized in the chart below.

Ankle ROM in Degrees	MEB ~5 Mos. Pre-Sep	VA C&P ~8 Mos. Post-Sep	
	Left	Right	Left	Right	
Dorsiflexion (0-20)	Normal ankle motion	10	20	
Plantar Flexion (0-45)		30	45 	
Comment	Pos. planovalgus deformity L > R; Pos. tenderness to palpation	Pos. painful motion	No painful motion; decreased strength	
		Normal gait; No Deluca criteria	
§4.71a Rating	10%*	10%*	10% (VA 10%)	0% (VA 0%)	
	PEB 10%		
*IAW VASRD 4.40, Functional Loss

The Board directed attention to its rating recommendation based on the above evidence.  The PEB coded the planovalgus feet, bilateral, s/p SBA Implants condition as 5299 analogous to 5284 (other foot injuries) and rated at 10% consistent with “moderate.”  The Board notes that VASRD code 5284 is not applicable to bilateral conditions.  The VA coded the planovalgus left foot s/p surgery condition as 5284 and rated at 10% and the planovalgus right foot s/p surgery condition as 5284 and rated at 0%.  The Board notes that “planovalgus feet” and pes planus (flat feet) represent the same condition.  All evidence in the treatment record clearly documented complaints of bilateral foot pain both before and after the surgical procedures.  The Board considered VASRD code 5276 (acquired flatfoot) for its rating recommendation noting that this code can be applied to bilateral conditions.  Board members agree that the CI did not meet the rating criteria of indication of swelling on use or characteristic callosities as required for the severe bilateral rating under 5276.  The CI met the moderate rating criteria for acquired flatfoot (weight-bearing line over or medial to great toe, inward bowing of the tendo achillis, pain on manipulation and use of the feet) which can be applied to one or both feet for a 10% rating and would be of no benefit to the CI.  The Board considered the coding of 5284 (to be applied separately to each foot) and the 10% moderate rating versus the 20% moderately severe rating.  There is ample documentation that the CI had documented bilateral foot pain that did not respond to initial surgical treatment.  After removal of the left foot’s surgical implant the CI’s left foot pain had decreased.  The evidence documents that even 8 months after separation, the CI’s right foot continued to have “decreased strength” with normal ankle ROM; while her left foot had painful motion with a decreased ankle ROM.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), §4.40 and § 4.7, the Board recommends a disability rating of 10% for the right planovalgus condition and 10% for the left planovalgus condition both coded 5284.

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 planovalgus foot condition, the Board unanimously recommends a disability rating of 10%, coded 5284 IAW VASRD §4.71a.  In the matter of the left planovalgus foot condition, the Board unanimously recommends a disability rating of 10%, coded 5284 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:

UNFITTING CONDITION	VASRD CODE	RATING	
Right Planovalgus Foot	5284	10%	
Left Planovalgus Foot	5284	10%	
COMBINED (w/ BLF)	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140122, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

MEMORANDUM FOR COMMANDER, NAVY PERSONNEL COMMAND
		   DEPUTY COMMANDANT, MANPOWER & RESERVE AFFAIRS
	                          
Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS          

Ref:   (a) DoDI 6040.44
       (b) PDBR ltr dtd	31 Jul 15 ICO XXXXXXXXXXXXXXX
       (c) PDBR ltr dtd 31 Jul 15 ICO XXXXXXXXXXXXXXX
       (d) PDBR ltr dtd 27 Jul 15 ICO XXXXXXXXXXXXXXX
	 (e) PDBR ltr dtd 24 Jul 15 ICO XXXXXXXXXXXXXXX
	 (f) PDBR ltr dtd 25 Jul 15 ICO XXXXXXXXXXXXXXX

1.  Pursuant to reference (a) I approve the recommendations of the Physical Disability Board of Review set forth in references (b) through (f).

2.  The official records of the following individuals are to be corrected to reflect the stated disposition:

     a. XXXXXXXXXXXXXXX, former USN:  Entitlement to disability severance pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge.

     b. XXXXXXXXXXXXXXX, former USMC:  Entitlement to disability severance pay with a 20 percent disability rating (increased from 0 percent) effective date of discharge. 

     c. XXXXXXXXXXXXXXX, former USN: Entitlement to disability severance pay with a 10 percent disability rating (increased from 0 percent) effective date of discharge. 

     d. XXXXXXXXXXXXXXX, former USN: Entitlement to disability severance pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge.

     e. XXXXXXXXXXXXXXX, former USMC: Entitlement to disability severance pay with a 20 percent disability rating (increased from 0 percent) effective date of discharge. 
     
3.  Please ensure all necessary actions are taken to implement these decisions, including the recoupment of disability severance pay, if warranted, and notification to the subject members once those actions are complete.