RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-00922
BRANCH OF SERVICE:  Army	                        SEPARATION DATE:  20090407

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an activated National Guard E2, Basic Trainee, medically separated for “bilateral calcaneal stress fractures and left 1st metatarsal stress fracture” with a disability rating of 20%.  

CI CONTENTION:  His condition continues to worsen and negatively impact his daily activities.  The CI’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 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 - 20090320	VARD -20090629	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Calcaneal Stress Fractures and Left 1st Metatarsal Stress Fracture	5299-5284	20%	Status Post Left Calcaneal Stress Fracture of Left Foot with Left First Metatarsal Fracture	5299-5283	10%	20090518	
			Status Post Right Calcaneal Stress Fracture	5299-5283	10%	20090518	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Bilateral Calcaneal Stress Fractures and Left 1st Metatarsal Stress Fracture.  The service treatment record (STR) and Medical Evaluation Board (MEB) narrative summary (NARSUM) documented a left foot injury during the second week of basic training in September 2008 (7 months pre-separation).  At a primary care visit in September 2008, the examiner documented bilateral ankle edema with tenderness and a nonspecific decrease in range of motion (ROM).  There was also left foot swelling and tenderness, and “normal” foot motion with pain, and the gait was not addressed.  Radiographic evaluations (X-rays and bone scan) in September and November 2008 documented stress fractures of the bilateral calcaneal bones and the left metatarsal base.  Despite treatment, the bilateral heel and foot condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and the CI was referred for an MEB.  The MEB forwarded “bilateral calcaneal stress fractures and left 1st metatarsal stress fracture” for PEB adjudication.  

The MEB NARSUM examination was performed on 6 February 2009 (2 months pre-separation).  The CI reported bilateral heel and left foot pain (at the 1st metatarsal).  The examiner documented bilateral ankle dorsiflexion to 0 degrees (normal 20) without pain; bilaterally tender heels, without swelling; bilaterally severe pes planus.  There was tenderness at left 1st metatarsal dorsally, without swelling.  There was no weakness, normal strength, and a normal gait.  On the MEB DD Form 2808 (same day), the examiner documented tenderness over the 1st metatarsal base with no edema and “normal” arches.  

At the VA Compensation and Pension (C&P) examination performed on 18 May 2009 (1 month post-separation), the CI reported constant 7/10 pain, made worse with stair climbing.  He denied use of crutches, braces, cane or corrective shoes; and denies effect of his condition on his employment.  The examiner documented normal gait, no crepitus and no edema, and a normal shoe wear pattern.  Bilateral ankle dorsiflexion was to 5 degrees, and plantar flexion was to 20 degrees (normal 45).  Pain was noted along the medial and lateral aspects of both heels during ankle range of motion.  

The Board directed attention to the rating recommendation based on the above evidence.  The PEB rated 10% for each foot and issued a combined rating of 20%, analogously coded 5299-5284 (foot injuries, other).  The VA rated 10% for each foot separately.  Both were analogously coded 5299-5283 (tarsal, or metatarsal bones, malunion or nonunion of), citing painful motion for the right foot, and “moderate” symptoms of malunion for the left foot.  The Board first considered the fitness implications for each ankle condition.  In this case the bilateral calcaneal and left foot condition was profiled, determined to fail retention standards, and implicated in the commander’s statement.  Members agree therefore that each ankle condition was separately unfitting and that identical coding and ratings were applicable.  The Board also noted that the left calcaneal stress fracture and the additional left 1st metatarsal fracture were conditions that were intertwined and not separately ratable.  More than one rating based on the same impairment is prohibited (§4.14 avoidance of pyramiding).  The overall ankle impairment was subsumed under the ratings for the ankle by both the PEB and the VA.  

The Board next considered the evidence for rating.  All Board members agreed that the MEB NARSUM and VA documentation of normal gait and strength, lack of swelling or weakness, normal shoe wear, lack of interference with employment and use of assistive devices, along with the limitations of motion in evidence approximated a “moderate” level of disability, supporting the 10% disability rating for each foot.  A higher rating of 20% was not indicated in the absence of markedly limited ROM of the ankles.  The Board considered whether ratings under the VASRD code for other foot injuries (5284) and alternative ankle and analogous codes provided for a higher rating (§4.7); however, all Board members agreed that the impairments in evidence did not support a higher rating.  The Board agreed that separate ratings for each ankle were of no benefit to the CI nor did it provide for a higher rating.  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 calcaneal and left metatarsal stress fracture conditions.  

BOARD FINDINGS:  In the matter of the left and right ankle conditions 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 20140221, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAMR-RB

MEMORANDUM FOR Commander

SUBJECT: Department of Defense Physical Disability Board of Review Recommendation
for XXXXXXXXXXXXXXXXXXXX, AR20160009943 (PD201400922)

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