RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	     CASE:  PD-2014-00799
BRANCH OF SERVICE:  Army 		SEPARATION DATE:  20080627

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Health Care Specialist, medically separated for “bilateral Pes Cavus”(feet condition), with a disability rating of 10%. 

CI CONTENTION:  His condition continues to worsen and negatively impact his daily activities.  The 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 - 20080611	VARD - 20100713	
Condition	Code	Rating	Condition	Code1	Rating1	Exam	
Bilateral Pes Cavus	5278	10%	Congenital Cavus Foot…Left	5278-5020	10%	20080814	
			Congenital Cavus Foot…Right	5278-5020	10%		
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY:  

Bilateral Pes Cavus.  The entrance examination dated 10 October 1996 noted a normal arch; the separation examination 13 months later on 7 November 1997 had the box for “feet” checked normal.  A second accession examination on 31 July 2003 recorded mild pes cavus (high arch) which was asymptomatic.  The first clinical record in evidence for the feet is an X-ray report for weight bearing X-rays of the feet which was dated 20 June 2007.  The CI complained of being “pigeon toed” and denied any trauma.  The X-rays were normal.  A bone scan on 19 July 2007 was positive for shin splints, but the feet were unremarkable other than a small sesamoid bone at the left great toe.  The CI was referred to podiatry where he was diagnosed with congenital talipes cavus (high arch) when seen on 24 July 2007.  He was also noted to have inflammation of the sesamoid bone (noted above) and an acquired pronation of the foot (inward rolling of the foot).  X-ray studies specifically of the sesamoid bones were normal though.  He was seen by a different podiatrist on 17 September 2007 and reported high arches, pain in the long bones of the feet (metatarsalgia), and painful feet.  He was again noted to have pes cavus, but now thought to have supination (rolling of the foot outward).  Magnetic resonance imaging (MRI) of the feet on 26 September 2007 showed inflammation of the posterior tibialis tendon (this can cause pain in the feet; the tendon holds up the arch and supports it in walking) and metatarsal adductus (a congenital abnormality, also called pigeon toed, in which the long bones of the feet turn inwards).  The ankle ligaments and plantar fascia were normal.  In addition, the right ankle shoed evidence of inflammation of the joint between the first metatarsal and great toe as well as indications of a sprain or degeneration.  At follow-up in podiatry on 1 October 2007, it was noted that these conditions were not amendable to surgical correction and would be aggravated by carrying heavy loads.  The CI was next seen in orthopedics on 13 October 2007 and it was determined that his conditions did not meet retention standards and a Medical Evaluation Board (MEB) was recommended.  A pain clinic evaluation on 6 December 2007 noted that the CI had tenderness over the inside aspect of the soles of the feet, was tender with stretching of the plantar fascia, and tender to palpation of the balls of the feet.  At the MEB examination on 21 December 2007, the CI reported the use of orthotics, but ongoing foot pain.  The MEB physical examiner noted bilateral tender plantar fasciae and pes cavus.  The Board noted that plantar fasciitis was not diagnosed prior to separation and that the CI had multiple orthopedic and podiatry evaluations.  The MRIs accomplished on 26 September 2007 showed normal plantar fascia.  The narrative summary (NARSUM) was dated 4 June 2008, 3 weeks prior to separation.  It noted that the CI had been treated with medications, light duty, and orthotics without resolution of his pain.  An examination done that day showed that the heels and balls of the feet were tender bilaterally.  The right arch was mildly tender to palpation; the left arch was not tender.  The arches were obviously high.  Standing on his toes was painful, but standing on his heels was not.  The range of motion was noted to be full.  Talipes cavus was diagnosed, but plantar fasciitis was not.  He was thought to have a congenital condition which was aggravated by service.  At the VA Compensation and Pension (C&P) examination performed on 7 August 2008, 6 weeks after separation, the CI reported the use of orthotics and a night splint.  His pain was worse in the morning and improved throughout the day.  He had a normal gait.  The range of motion of the toes was normal.  He was thought to have bilateral pes cavus with plantar fasciitis.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral pes cavus condition at 10%, coded 5278 (claw foot, pes cavus).  The VA also used the 5278 code, albeit analogously.  However, it determined that the condition was congenital and not ratable.  A subsequent review by a Decision Review Officer (DRO), dated 13 July 2010, determined that the feet were permanently aggravated by service.  The DRO changed the codes to 5278-5020 (synovitis) and assigned 10% ratings for each foot, retroactive to separation.  The decision was based, at least in part, on a C&P accomplished on 3 June 2010, almost 2 years after separation and outside the 12-month window for evaluations to be assigned a higher probative value for rating at separation.  The VA description was changed from congenital cavus foot with plantar fasciitis to plantar fasciitis with congenital cavus foot for each foot.  The Board noted that while the plantar fasciae were noted to be tender on several pre-separation examinations, plantar fasciitis was not diagnosed until after separation even though evaluated by both podiatry and orthopedics at multiple appointments.  Bilateral MRIs did not show an abnormal plantar fascia.  The VASRD description for 10% rating for pes cavus is “great toe dorsiflexed, some limitation of dorsiflexion at ankle, definite tenderness under metatarsal heads.”  The Board determined that this best fits the clinical findings in evidence.  A 10% rating is supported for either a unilateral or bilateral condition.  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 pes cavus condition.  
BOARD FINDINGS:  In the matter of the bilateral pes cavus 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 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 20140218 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, AR20160006028 (PD201400799)

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