RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX		CASE:  PD-2014-00623
BRANCH OF SERVICE:  Army		SEPARATION DATE:  20051211

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (Infantryman) medically separated by a Reconsideration Physical Evaluation Board for “right calcaneal fracture”; with a combined disability rating of 20%.

CI CONTENTION:  The applicant makes no specific contention in his application.  His 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 - 20050906	VARD - 20060424	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Calcaneal Fracture	5099-5003	20%	Residuals, Calcaneal and Ankle Fracture with Calcaneal Spur and Arthritis, Right	5271-5284	20%	20060403	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  50%	

ANALYSIS SUMMARY:  

Right Calcaneal Fracture.   According to notes in the service treatment record and the narrative summary (NARSUM) the CI was injured by an improvised explosive device blast 20 July 2004.  He sustained an open fracture of the left tibia and an open fracture of the right heel.  Left tibia/fibula X-rays on 28 July 2004 noted a fragmented fracture of the proximal to middle left tibia and right foot X-rays noted a multi-fragmented, displaced fracture of the calcaneus (heel bone), with non-displaced fractures of the talus and cuboid bones (bones above and anterior to the calcaneus, respectively.  The talus forms the ankle joint with the tibia and fibula.  The left tibial fracture was treated with an external fixator and healed without complications.  The right foot was casted for 3 months and the CI then started physical therapy.  Despite maximal treatment, the right heel pain continued and the orthopedic surgeon recommended an MEB.

At the MEB NARSUM exam performed 3 March 2005, performed 9 months before separation, the CI reported the right foot pain had not improved with physical therapy.  He reported constant right heel pain treated with narcotic pain medication as needed daily, that he altered his gait to walk, and was unable to walk without shoes.  The MEB physical exam noted tenderness to palpation and deformity of the calcaneus (“gross widening…compared to the left”), loss of the calcaneal fat pad under the heel of the foot, and a well-healed but tender scar of the bottom of the calcaneus.  There was normal vascular perfusion and sensation of the foot.  The MEB examiner noted decreased dorsiflexion of the right ankle compared with the left and referenced physical therapy ROM measurements, which were not in record.  Right foot X-rays 3 March 2005 showed a healed fracture of the calcaneus. The MEB examiner indicated the CI’s pain rating was “constant” and “moderate” and the CI was still in PT.

The MEB DD Form 2808, Report of Medical Examination, dated 20 June 2005, 6 months before separation, indicated the CI continued to have right ankle pain despite physical therapy and underwent ankle arthroscopy on 30 March 2005 for debridement.  The MEB DD Form 2808 exam noted tenderness to palpation of the right heel without limitation of motion and a normal gait.  Lower extremity strength and reflexes were normal, but the CI was unable to heel walk secondary to pain.

At the VA Compensation and Pension (C&P) exam performed 3 April 2006, 3 months after separation, the CI reported constant right heel pain aggravated by weight bearing activities.  The CI reported he could walk for forty minutes before having to stop due to pain.  He denied flare-ups or incapacitating episodes and reported use of anti-inflammatory medication twice daily.  The VA exam noted a normal gait and no assistive devices for ambulation.  On exam there were well healed scars from the arthroscopy, scars of the bottom of the foot and ankle with loss of tissue and discoloration, and a callus on the heel.  There was a bony protuberance of the right heel at the base of the Achilles tendon.  The exam noted an abnormal stance with weight-bearing on the right forefoot.  The CI could toe walk, but was unable to heel walk due to pain.  The ankle was stable.  Ankle range-of-motion was dorsiflexion 20 degrees (normal 20) and plantar flexion 20 degrees (normal 45).  Pain was noted with pronation of the foot and there was no additional loss of ROM with repetition.  Ankle X-rays were reported as healed fracture deformity of the posterior tibia, degenerative joint disease of the ankle, and no residual deformity of the calcaneus, and calcaneal spur was noted.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the foot condition 20%, coded 5099-5003, and cited the USAPDA pain policy.  The VA also rated the foot condition 20%, but coded 5271-5284 (Other foot injury with limited ankle motion).  The Board considered if there was path to a higher rating than the 20% rating determined by the PEB with any applicable code.  Members first reviewed the rating criteria of 5284, which are subjective, with 10% rating for “moderate”, 20% rating for “moderately severe” and 30% for “severe” foot injury.  After deliberations, members agreed that the evidence of abnormal weight bearing on the right foot (noted at the C&P exam), but with an otherwise well compensated gait (“normal”) noted at both the DD Form 2808 and C&P exams and lack of requirement of any assistive devices for ambulation supports characterizing the disability due to the foot condition as moderately severe, but not severe.  The Board next noted that 20% is also the highest rating coding as 5271 (Limitation of ankle motion) for “marked” limitation of motion, and the highest rating for a single major joint coded according to 5003 rating criteria is 10% for imaging evidence of degenerative joint disease with limited motion.  Additionally, there was no evidence in record of malunion of the tarsal or metatarsal (foot) bones or ankylosis of the ankle to support a higher rating.  Thus, the Board determined that the foot condition could be rated 20% and no higher and that the PEB reliance on the USAPDA pain policy was not detrimental to arriving at the highest rating in this case.  Therefore, no change to the PEB’s coding choice is recommended.  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 right foot condition.

BOARD FINDINGS:  In the matter of the right foot condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  There were no other conditions within the Board’s scope of review for consideration. 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 20140130, 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, AR20160002522 (PD201400623)

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