RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXX	CASE:  PD-2014-01239
BRANCH OF SERVICE:  Army	BOARD DATE:  20150206
Separation Date:  20080617

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-2 (Trainee) medically separated for a bilateral foot injury.  The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS) or satisfy physical fitness standards.  He was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  The bilateral foot injury, characterized as “right foot and left ankle stress reactions” was the only condition forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. The Informal PEB adjudicated “bilateral foot injury” as unfitting, rating each foot at 10%, with application of the Veteran’s Affairs Schedule for Rating Disabilities (VASRD).  The CI made no appeals and was medically separated with a 20% disability rating.

CI CONTENTION:  “Please refer to VA Rating Decision.”

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:

Service IPEB – Dated 20080602	VA - (12 Mos. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Foot Injury	5284	10%	Left Ankle Sprain, s/p Talus Fracture with Residual Plantar Fasciitis	XX*	20%	20090529	
Right Foot Injury	5284	10%	Right Foot Stress Fracture, Right Fifth Metatarsal Base with Metalarsalgia	XX*	10%	20090529	
			Right Ankle Sprain s/p Talus Fracture with Residual Plantar Fasciitis	XX*	10%	20090529	
Other x 0 (Not in Scope)	Other x 5	
Combined:  20%	Combined:  50%	
Derived from VA Rating Decision (VARD) dated 20090731 (most proximate to date of separation [DOS])
* Ratings in chart are taken from the VARD closest to separation; however Rating Codes are missing from CI packet.

ANALYSIS SUMMARY:  

Left Foot Injury Condition.  The CI developed left ankle and foot pain during the 8th week of Basic Training due to strenuous activities.  These symptoms did not exist prior to service (EPTS).  The Podiatrist noted that the CI reported pain over the dorsal aspect of the forefoot, plantar aspect under the forefoot, which worsened with standing, walking and running.  There were physical findings of swelling, enlargement and pain with ROM.  The examiner ordered a surgical boot/shoe and an X-ray.  A Bone Scan demonstrated a moderate-to-marked focal uptake of increased activity which involved the superior surface of the left talus consistent with a stress fracture.  The left foot X-ray was normal.  The Medical Clinic examiner documented left ankle talus head TTP.  The MEB Narrative Summary (NARSUM) exam approximately 2 months prior to separation documented left ankle pain was resolving until the CI resumed light jogging and running, which made the pain worse.  The CI occasionally took narcotic and non-narcotic medications for the pain.  The examiner concluded that because of the functional limitations and pain associated with the CI’s condition, he could not perform his duties.  The MEB NARSUM physical exam findings are summarized in the chart below.  The commander’s statement indicated that the CI did not perform any hard labor duties and was in a holding detachment pending discharge.  The VA Compensation and Pension (C&P) exam performed 11 months after separation documented that the CI reported constant pain, with cold weather and activities he would have a flare-up with swelling, weakness, an inability to stand, an inability to drive, and walking limited to 200 to 300 feet.  He wore his ankle braces daily and would work at his job with pain.  The VA C&P physical exam findings are summarized in the chart below.

There were two range of motion (ROM) evaluations in evidence, with documentation of additional ratable criteria, which the Board weighed in arriving at its rating recommendation; as summarized in the chart below.

Left Ankle ROM (Degrees)	MEB 2.5 Mos. Pre-Sep	VA C&P 11.5 Mos. Post-Sep	
Dorsiflexion (20 Normal)	Full Range of Motion	4	
Plantar Flexion (45)		10	
Comment	Tenderness to palpation (TTP) head of talus; No painful motion; No instability	Pos. painful motion; No Deluca criteria; uses a cane walks slowly	
§4.71a Rating	10% (PEB 10%)	10% (VA 20%)	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB coded the left foot Injury condition as 5284 (other foot injuries) and rated at 10% for “moderate.”  The VA considered the left ankle sprain, s/p talus fracture with residual plantar fasciitis and rated at 20% for “…for marked limited motion of the ankle.”  The Board considered the discrepancy between the PEB and VA ratings and members agreed that the PEB rating was granted after a period of significant rest, which resulted in decreased symptoms as supported by the evidence.  The C&P exam occurred while the CI was working part-time as a bus driver and represents post-separation worsening.  The evidence in the STR documented the CI had chronic moderate pain with functional impairment that interfered with his MOS activities.  At the time of separation, the CI’s foot disability did not raise to the moderately severe level as required for the next higher 20% 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 left foot injury condition.

Right Foot Injury Condition:  The CI developed right ankle and foot pain during the 8th week of Basic Training due to strenuous activities.  These symptoms were not EPTS.  The Medical Clinic provider noted that the CI reported dorsal right midfoot pain with physical exam findings of mild swelling across the top of the metatarsals, pain with full range of motion (ROM), tenderness to palpation (TTP) and swelling.  A right foot X-ray performed on the same day showed moderate degenerative changes of the first MTP joint.  The Podiatrist noted that the CI reported pain over the dorsal aspect of the forefoot, plantar aspect under the forefoot which worsened with standing, walking and running.  There were physical findings of the right foot arch which was lower with deformity, swelling, enlargement and pain with ROM.  A Bone Scan demonstrated a moderate to marked focal uptake of increased activity which involved the superior surface of the right talus consistent with a stress fracture.  The CI followed with podiatry for the remainder of 2007 and there was documentation of some improvement in the right foot pain.  The initial commander’s statement indicated that the CI’s diagnosis of right foot and left ankle stress reactions limited his participation in any part of OSUT, BCT or AIT and the commander strongly recommended that the CI be placed in Holding Detachment.  The MEB Narrative Summary (NARSUM) exam approximately 2 months prior to separation documented right ankle pain was resolving until the CI resumed light jogging and running which made the pain worse.  The CI occasionally took narcotic and non-narcotic medications for the pain. The examiner concluded that because of the functional limitations and pain associated with the CI’s condition, he could not perform his duties.  The examiner rated the pain according to the American Medical Association (AMA) pain scale at slight and constant.  The MEB NARSUM physical exam findings are summarized in the chart below.  The CI was given a permanent L3 profile for right ankle stress reactions with code C restrictions noted on the profile.  The second commander’s statement indicated that the CI did not perform any hard labor duties and was in a holding detachment pending discharge.  The VA Compensation and Pension (C&P) exam documented that the CI reported constant right foot pain, moderate at rest but with cold weather and activities, he would have a flare-up with swelling and weakness.  He wore his ankle braces daily and would work at his job with pain.  The VA C&P physical exam findings are summarized in the chart below.

There were two range of motion (ROM) evaluations in evidence, with documentation of additional ratable criteria, which the Board weighed in arriving at its rating recommendation; as summarized in the chart below.

Right Ankle ROM (Degrees)	MEB 2.5 Mos. Pre-Sep	VA C&P 11.5 Mos. Post-Sep	
Dorsiflexion (20 Normal)	Full Range of Motion	18	
Plantar Flexion (45)		16	
Comment	Pos. antalgic gait & tenderness to palpation; No pain on motion; No instability	No swelling or tenderness; Pos. painful motion; No Deluca criteria	
§4.71a Rating	10%	10% (VA 10%)	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB coded the right foot injury condition as 5284 and rated it 10% for “moderate.”  The VA rated the right ankle sprain s/p talus fracture with residual plantar fasciitis condition at 10%.  The evidence in the STR documented that the CI had chronic moderate pain with functional impairment which interfered with his MOS activities.  The Board considered the discrepancy between the ROM measurements documented in the NARSUM and the C&P exam.  At the time the NARSUM was prepared, the CI’s right foot condition was less symptomatic as he had been less active; while at the time of the C&P exam the CI had been working part-time as a bus driver and represented post-separation worsening.  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 injury condition.

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 left foot injury condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the right foot injury 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.

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 20140306, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

							
XXXXXXXXXXXXXXX
President
DoD Physical Disability Board of Review

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 XXXXXXXXXXXXXXX, AR20150009943 (PD201401239)

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						     XXXXXXXXXXXXXXX
						     Deputy Assistant Secretary of the Army
						          (Review Boards)
						         
CF: 
(  ) DoD PDBR
(  ) DVA