RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX  	 CASE:  PD-2014-01216  
BRANCH OF SERVICE:  Army  	 BOARD DATE:  20150514  
SEPARATION DATE:  20081210  

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a National Guard E-2 (Basic Trainee) medically separated for a bilateral foot condition.  The condition could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty or satisfy physical fitness standards.  She was issued a permanent L3 profile and referred for a Medical Evaluation Board.  The “bilateral foot stress fractures” was the only condition forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The Informal PEB adjudicated “bilateral foot injuries due to stress fractures of the talus, navicular and first and second metatarsal bases” as unfitting, rated 20% (specifying 10% for each foot and application of the bilateral factor), citing criteria of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The CI made no appeals and was medically separated.  

CI CONTENTION:  The CI elaborated current disability attributed to her feet, ankles, and knees without an explicit contention.  

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 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 IPEB – Dated 20081014	VA* (~6 Mo. Post-Separation) 	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Foot Injuries Due to Stress Fractures…(de facto 10% Right + 10% Left)	5284	20%	Stress Fractures, Left Foot	5283	10%	20090603	
			Stress Fractures, Right Foot	5283	10%	20090603	
Other x 0  (Not in Scope)  	Other x 0  		
RATING:  20%	RATING:  20%	
*Derived from VA Rating Decision (VARD) dated 20090923 (most proximate to date of separation (DOS)).   

ANALYSIS SUMMARY:  

Right and Left Foot.  The first entry in the service treatment record (STR) addressing this condition is from March 2001 (3 weeks after entry and 9 months prior to separation), and noted an onset of bilateral ankle and foot pain associated with the rigors of basic training.  X-rays were normal, but the pain persisted and a bone scan revealed bilateral stress fractures of the tarsal and metatarsal bones (specifically talus, navicular, and 1st and 2nd metatarsals [with an incidental note of uptake in tibial plateaus]).  The CI was treated conservatively (physical therapy (PT), orthotics, profiles, and a trial of convalescent leave), but did not improve adequately to resume training.  An antalgic gait was noted in numerous STR entries, although several documented a normal gait.  The last Primary Care entry from August 2008 (14 weeks prior to separation) documented a normal gait, normal ankle exams, bilateral foot tenderness, and “full” range-of-motion (ROM).  Goniometric ROM measurements by PT were performed during this same period and recorded right ankle dorsiflexion (DF) to 10 degrees (normal 20) and plantar flexion (PF) to 45 degrees (normal), with left ankle DF to 20 degrees and PF to 45 degrees.  There is no STR evidence for more significant ROM limitation, joint deformity or instability, or physician directed bed rest or incapacitation.

The narrative summary (NARSUM) was conducted 24 September 2008 (10 weeks prior to separation), with evidence supplemented and corroborated by an outpatient entry from the same podiatrist on the same day.  The examiner documented constant bilateral foot pain “shooting from the medial ankle” rated 3/10 and the CI’s report that, “She cannot walk due to the pain.”  The only specified limitation was that she was unable “to carry the loads in a training environment or perform her military duties.”  The NARSUM physical examination recorded a “limping” gait, tenderness without swelling or deformity of the feet and ankles, and “full [ROM] of her ankle joints, subtalar [hindfoot] joints and metatarsophalangeal [forefoot and toes] joints.”  The permanent L3 profile prohibited unlimited walking or running, but permitted walking and biking as tolerated.  The commander’s performance statement recognized the profile limitations and specified that the CI performed alternate duties well.  

A VA Compensation and Pension (C&P) general examination was conducted 3 June 2009 (6 months after separation), and documented “moderate” bilateral foot and ankle pain “1-2 days weekly” which was “aggravated by long standing > 120 minutes ... [and] ... walking distance > 1 mile.”  The physical examination recorded a normal gait with normal strength and neurological findings, deferring to a VA podiatry examination for specific findings.  The VA podiatrist documented a report of “pain ... swelling ... stiffness ... fatigability ... weakness ... [and] ... lack of endurance” (objective examples of these subjective complaints were not elaborated), and specified that the CI was “able to stand more than 1, but less than 3 hours ... able to walk more than ¼ mile but < 1 mile.”  The examiner documented that the CI was employed full time with no work loss due to the condition.  The physical examination recorded a normal gait, bilateral foot tenderness, and specified the absence of “painful motion, swelling, instability, weakness, [and] abnormal weight bearing.”  The VA podiatrist specifically excluded various ratable foot deformities (analogous code considerations): hammertoe, hallux valgus or rigidus, pes cavus, pes planus, and “other foot deformity.”  Neither the general nor podiatry C&P examinations provided foot or ankle ROM measurements.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB’s de facto separate ratings were under code 5284 (foot injuries, other), with the DA Form 199 decision citing the “moderate” criterion for the 10% determinations.  The VA’s equivalent rating was under code 5283 (tarsal or metatarsal bones, malunion or nonunion), citing the “moderate” 10% criterion for that code.  Incidentally, it is noted that no malunion or nonunion was present in this case, and 5283 is justified only by analogous designation.  Both 5284 and 5283 offer a 20% rating for “moderately severe” and 30% for “severe” disability.  The Board first considered if separate ratings for foot and ankle disability were defensible in this case, but members agreed that no separately ratable impairment was discernable without violation of VASRD §4.14 (avoidance of pyramiding).  Accepting that the above 5284 and 5299-5283 are justified options, the only alternate code available under VASRD §4.71a applicable for consideration in this case is 5271 (ankle, limited motion).  The 20% rating under 5271 requires assessing ROM limitation as “marked,” and the ROM evidence indicates at most a 50% reduction in dorsiflexion and no significant reduction of plantar flexion.  Members agreed that this degree of ROM limitation is not reasonably characterized as marked; thus, code 5271 offers no advantage.  Finally the Board deliberated whether a higher rating under 5284 or 5299-5283 could be justified, assessing disability as “moderately severe” or “severe” (as above).  The functional evidence indicates that excessive standing, walking, or running were the primary limitations at separation, and that there was no objective occupational impairment.  Members thus agreed that “moderate” was a fair assessment of the disability.  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 and left foot conditions.  

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 and left foot 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.

RECOMMENDATION:  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 20140303, 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 XXXXXXXXXXXXXXXXXXXX, AR20150014196 (PD201401216)

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:

Encl						     
						         
CF: 
(  ) DoD PDBR
(  ) DVA