RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	    CASE:  PD-2014-00830
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20080608

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (Signal Support Systems Specialist) medically separated for diabetes mellitus (DM) and pes planus.  The conditions could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS).  He was issued a permanent P3U3 profile and referred for a Medical Evaluation Board (MEB).  “Insulin dependent diabetes mellitus” and “severe pes planus deformity,” were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also identified and forwarded 4 medically acceptable conditions (left cataract, status post right cataract surgery; hypertension; diabetic neuropathy; and, bilateral mild to moderate hallux valgus) for PEB adjudication.  The Informal PEB (IPEB) adjudicated “insulin dependent diabetes mellitus” and “pes planus deformity” as unfitting, rated 20% and 0%, with application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The remaining conditions were determined to be not unfitting.  The CI made no appeals and was medically separated.  

CI CONTENTION:  His conditions continue to worsen and negatively impact his daily activities.  Additionally, he also contends for his PTSD condition.  His complete submission is at Exhibit A.  

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:  

Admin Corr IPEB - Dated 20080314	VA* - (~4 Mos. Pre-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
IDDM	7913	20%	Diabetes Mellitus Type I with Peripheral Neuropathy …	7913	20%	20080222	
Diabetic Neuropathy	Not Unfitting 					
Pes Planus Deformity	5299-5276	0%	Bilateral Pes Planus	5299-5276	10%		
Other MEB/PEB Conditions x 3 (Not In Scope)	Other x 0	
RATING:  20%	RATING:  30%	
*Derived from VA Rating Decision (VARD) dated 20081008 (most proximate to date of separation [DOS]).  

ANALYSIS SUMMARY:  

Insulin Dependent Diabetes Mellitus (IDDM).  The CI was admitted on 23 May 2007 for an elevated blood sugar discovered on random blood sugar testing in a post-deployment assessment.  He was treated with oral medications and insulin over the next 3 days and then discharged.  He reported that for the past year he had noted increased thirst, hunger, urination, blurred vision, numbness, and weight loss.  The action officer observed that these are classic symptoms for uncontrolled DM.  His evaluation was most consistent with Type II DM (insulin resistant).  Complications of DM include nerve, kidney, eye, and vascular issues.  These are discussed sequentially, in chronological order.  

He was seen on multiple occasions by neurology and found to have a diabetic polyneuropathy, primarily manifested by bilateral foot pain, which was well controlled by Cymbalta.  There was a sensory loss initially in a glove and stocking distribution which is typical for DM neuropathy.  The MEB examination on 28 August 2007, 9 months prior to separation, noted a normal neurological examination.  The narrative summary (NARSUM) noted was dated 16 October 2007, 7 months prior to separation.  It noted that the CI’s neurological symptoms (foot pain) had completely resolved on Cymbalta.  The examiner noted that the CI had no real limitations other than the requirement for regular injections and the need to refrigerate the insulin.  A podiatry examination for the MEB was done on 16 October 2007 and noted that the sensory changes of tingling and burning were resolved.  At the VA Compensation and Pension (C&P) examination performed on 22 February 2008, 4 months before separation, the CI reported hypoglycemia while sleeping 3-4 times a month and that these were accompanied by night sweats.  He reported a good response to the foot pain on Cymbalta.  On examination, he had a bilateral sensory loss on the bottom of the feet near the 4th toes and inside of the heels.  His pain was attributed to a neuropathy rather than to the coincident flat feet (pes planus; discussed below).  He also reported a burning sensation over 40% of the bottoms of his feet; however, his gait was normal.  An evaluation of his feet on 12 January 2009, 7 months after separation, revealed a normal diabetic foot examination with sensation intact to monofilament testing (the standard for discrimination).  

An evaluation by nephrology (kidneys) showed minimal protein loss in his urine and an otherwise unremarkable examination with normal renal function.  He was placed on Lisinopril for renal protection.  He did have blood in his urine though.  A CT scan on 17 March 2008 was negative for kidney stones.  On 24 March 2008, 3 months prior to separation, the hematuria was attributed to an infection and had been treated with antibiotics.  Subjectively, the CI felt better after treatment.  Following separation, the CI had further evaluation and a renal biopsy.  This was initially thought to show a lupus (a different disease process), but he was subsequently diagnosed with a diabetic nephropathy (kidney disease from the DM).  The nephrologist noted that his renal function remained normal at the 11 February 2009 (8 months after separation) visit though.  

The record also shows that the CI was diagnosed with bilateral cataracts which were removed and replaced with intra-ocular lenses.  On 4 October 2005, prior to the diagnosis of cataracts, the CI had a normal eye examination including the lenses and retina.  He was noted to be near sighted (myopic) which he had been at accession.  His prior eye examination had been in basic training, 5 months earlier.  An optometry evaluation for the DM was done on 2 August 2007.  Bilateral cataracts were noted.  However, the retinal examination was normal without evidence for diabetic retinopathy.  This was confirmed by an ophthalmologist 3 weeks later.  He subsequently had bilateral cataract extraction and intraocular lens placement in October 2007.  The Board found no actual documentation of the outcome of the surgery in evidence prior to separation.  However, a good outcome was implied in the records and supported by the VA eye C&P dated 30 October 2009 which noted good results.  

The CI was seen in the emergency room for chest pain on 12 July 2007.  A cardiovascular cause was excluded.  There were no other records found in evidence indicative of cardiovascular disease prior to separation.  The Board also noted that although the CI was on blood pressure medications for the renal protective effect, he was not diagnosed with hypertension (high blood pressure) prior to initiation of the medicines and typically had a normal or low normal blood pressure reading.  

The Board noted that one of the rating criteria for DM is regulation of activities, which is the as avoidance of strenuous occupational and recreational activities with the intention of avoiding hypoglycemic episodes.  The Board examined the profiles and the NARSUM to assess this.  On 22 June 2007, 4 weeks after the diagnosis of DM, the CI was issued a P3 profile which required that the CI have a companion for running and PT.  The commander noted that the CI was not able to go to the range, field exercises, or deploy due to his DM.  The NARSUM noted that the CI had no real limitations other than the requirement for regular medications which must be refrigerated.  However, he also noted that the CI was unable to carry and fire a weapon in addition to limitations from the pes planus condition.  On 19 October and 6 November 2007, podiatry limited the CI to light desk work and a shoe of comfort due to foot and ankle pain as well as “flat foot.”  Lifting a load was limited to 0 and then 10 pounds.  An L3 profile was issued both times.  No mention was made of the DM condition and a P1 profile was annotated.  The final P3L3 profile, dated 6 December 2007, listed bilateral flat feet and IDDM; the limitations from the previous profiles were combined without listing which condition warranted which limitation.  A memorandum to the PEB cited an opinion from the treating endocrinologist that the CI was only restricted from weapons when his blood sugar was not well controlled (<70 or >250).  The Board determined that “regulation of activities” was not, in fact, present.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the CI at 20%, coded 7913 (diabetes).  The VA also rated the DM condition at 20% initially, coded 7913, but later increased the rating to 40% in the 1 February 2010 rating decision citing a “clear and unmistakable error” in the prior evaluation.  The rater noted that the CI was restricted from lifting more than 15 pounds, was unable to carry a fighting load or shoot a weapon, and no road marches or prolonged standing.  The rater made no mention of the contribution to the limitation assigned by the podiatrist or the later modification in weapons access reported to the PEB.  The Board noted that these restrictions account for all the limitations cited by the rater for “regulation of activities.”  The Board opined that the rater erred in their assessment.  The Board also considered if compensable complications from DM were present at separation.  No comment was made for the cardiovascular system; otherwise, all were noted to meet retention standards.  The CI had normal renal function at a nephrology evaluation shortly after separation.  The sensory changes responded well to Cymbalta and to management of the DM.  Although the C&P examiner noted the presence of a neuropathy, other examinations both prior to separation and after separation documented a normal examination.  The evidence does not support the presence of an unfitting neuropathy at separation if one was indeed even present at separation.  The eyes were unremarkable other than bilateral cataracts which had successfully been treated.  As noted, no evidence of cardiovascular disease was in evidence prior to separation.  The Board determined that there were no compensable complications from DM present at separation.  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 DM condition.  

Pes Planus Deformity.  The CI was noted to have moderate, asymptomatic pes planus (flat feet) at accession.  An undated physical therapy note accomplished at in processing to his final posting, on/about 27 December 2005, documented that his foot arch was normal.  During the evaluation for the DM condition, the CI reported bilateral tingling in his feet for the past several months.  Weight bearing X-rays on 14 June 2007 showed bilateral pes planus with a large bone spur in the heel bones.  A bunion (hallux valgus) was also present.  The left foot was more impacted that the right.  Alignment was noted as normal.  The CI was then evaluated in podiatry on 19 July 2007 and reported a 1 month history of burning and tingling in both feet.  He was diagnosed with a severe, congenital foot deformity (pes planus) and given orthotics (shoe inserts).  Repeat X-rays on 19 July 2007 showed stable findings.  At the MEB examination, the examiner noted a mild, symptomatic pes planus.  The podiatry addendum to the NARSUM was dated 16 October 2007, 9 months prior to separation.  The CI reported that the burning and tingling had resolved with Cymbalta, but also that he had dull intermittent pain with long periods of marching.  This was attributed to the bilateral severe pes planus condition and the bilateral mild hallux valgus.  The Board noted though that the CI had been put on a profile which limited activities on 22 June 2007 and did not start the Cymbalta until the 3 August 2007 neurology appointment.  On examination, he was noted to have a significant flat foot deformity and mild to moderate bunions bilaterally as well as a reverse C-shape of the Achilles.  Tenderness was not recorded.  His subjective symptoms were noted to have resolved.  He was noted to have bilateral severe pes planus and hallux valgus; both conditions were medically unacceptable.  Due to his foot conditions, he was restricted from long road marches and long runs as well as carrying a fighting load at least 2 miles.  At the VA C&P examination performed 4 months before separation, the CI reported the onset of bilateral numbness, burning, and pain in his feet which was aggravated by walking and climbing mountains.  His symptoms were improved on Cymbalta.  He reported the use of orthotics and had a normal gait.  The feet were not tender to palpation.  The foot pain was attributed to the DM condition rather than the bilateral foot conditions.  The weight bearing line was over or medial to the great toe bilaterally.  The examiner made no comment on the presence of the bilateral hallux valgus and noted that the pes planus condition had no significant impact on daily activities of his occupation.  On 27 January 2008, podiatry reported that the hallux valgus condition, which was asymptomatic, met retention standards.  The pes planus condition did not.  The VA C&P for the feet on 29 October 2009, 17 months after separation, noted that the CI had pain in both feet with weight bearing activities.  He had no limitations in standing or walking though.  The bottoms of the feet were tender to palpation.  However, the weight bearing line was now over the great toes.  The gait was normal.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the pes planus deformity at 0%, coded 5299-5276 (analogous to flat feet).  The VA used the same code, but rated the condition at 10%, citing the weight bearing line over or medial to the great toe with inward bowing of the tendo-achilles, and pain on manipulation and use of the feet.  The Board considered the criteria for a 10% rating “moderate; weight-bearing line over or medial to great toe, inward bowing of the tendo-achilles, pain on manipulation and use of the feet.”  Tenderness was absent on the pre-separation VA C&P examination and not recorded on the podiatry addendum.  The pes planus condition was not thought to limit his activities of daily living or his occupation.  The alignment was noted to be normal on several sets of X-rays and the VA C&P remote from separation.  No comment regarding alignment was made on the podiatry evaluation.  The pre-separation C&P examiner attributed the pain to the DM condition rather than the pes planus.  The podiatrist indicated that the CI had pain with long marches, but did not then specifically comment on his status after treatment.  The post-separation C&P noted no limitations in standing or walking.  The gait was consistently recorded as normal.  The Board majority gave high probative value to the podiatry evaluation 9 months prior to separation which supported a 10% rating.  The majority also determined that the “weight bearing line was over or medial to the great toe” finding noted by the VA examiner pre-separation was sufficient to support a 10% rating at separation for the bilateral foot condition.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board majority recommends a disability rating of 10% for the pes planus condition coded 5276.  

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 diabetes mellitus condition and IAW VASRD §4.120, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the pes planus condition and IAW VASRD §4.71a, the Board majority recommends a disability rating of 10%, coded 5299-5276.  In the matter of the contended diabetic neuropathy condition, the Board unanimously recommends no change from the PEB determination as not unfitting.  

RECOMMENDATION:  The Board recommends that the CI’s prior determination be modified as follows; and, that the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective as of the date of his prior medical separation:  

CONDITION	VASRD CODE	RATING	
Insulin Dependent Diabetes Mellitus	7913	20%	
Pes Planus Deformity	5299-5276	10%	
RATING	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140219, 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, AR20160002539 (PD201400830)

1.  Under the authority of Title 10, United States Code, section 1554(a), I approve the enclosed recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) pertaining to the individual named in the subject line above to re-characterize the individual’s separation as a permanent disability retirement with the combined disability rating of 30% effective the date of the individual’s original medical separation for disability with severance pay.  

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:

	a.  Providing a correction to the individual’s separation document showing that the individual was separated by reason of permanent disability retirement effective the date of the original medical separation for disability with severance pay.

	b.  Providing orders showing that the individual was retired with permanent disability effective the date of the original medical separation for disability with severance pay.

	c.  Adjusting pay and allowances accordingly.  Pay and allowance adjustment will account for recoupment of severance pay, and payment of permanent retired pay at 30% effective the date of the original medical separation for disability with severance pay.

	d.  Affording the individual the opportunity to elect Survivor Benefit Plan (SBP) and medical TRICARE retiree options.

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:
						      					
Enclosure
					
CF: 
(  ) DoD PDBR
(  ) DVA