RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-01591
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20080731

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Metal Worker, medically separated for “chronic right foot pain” and “chronic left foot pain,” rated 10% and 10%, respectively, with a combined disability rating of 20%.

CI CONTENTION:  His conditions continue to worsen and he was not evaluated for PTSD. 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 - 20080515	VARD - 20080905	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Right Foot Pain	5279	10%	Status Post Open Reduction and Internal Fixation… 	5283	10%	20080407	
Chronic Left Foot Pain	5099-5003	10%	Sesamoiditis, Left Foot	5099-5024	0%	20080407	
Anxiety Disorder NOS	Not Unfitting 	PTSD	9411	NSC	20080415	
Insomnia Due to Stress	Not Unfitting 					
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Right Foot Condition.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s foot pain began during basic training.  He underwent right foot surgery with a bone graft in February 2007 to address a fracture of the second metatarsal.  Following surgery, conservative treatment did not result in improvement sufficient to allow unrestricted duty.  The MEB forwarded “bilateral foot pain” (specifically noting the left and right foot did not meet retention standards) for PEB adjudication.

The MEB NARSUM examination, dated 18 March 2008 (13 months after surgery and 4 months before separation) noted a tender foot to palpitation but that gait, alignment and mobility, coloration, and vascular and sensory function were normal.  The CI reported right foot pain that was constant and rated at 1-2/10 with elevation to 5/10 with more vigorous activity.  He was able to walk 2-3 miles at a slow pace without a significant increase in pain.  

At the VA Compensation and Pension (C&P) examination on 7 April 2008 (4 months before separation), the CI reported right foot pain without weakness, stiffness, swelling, or fatigability.   He had no flare-ups and took pain medication as needed.  His pain was precipitated by prolonged weight bearing, running or jumping.  Physical examination documented “sensitivity” with palpation of the foot/bone but normal arches with full weight bearing bilaterally.  The examiner recorded, “the biggest limiting factor to this veteran is pain, subjectively.”  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating under the 5279 code (metatarsalgia, anterior, unilateral or bilateral) citing pain and tenderness upon palpitation and functional loss.  The VA assigned a 10% rating under the 5283 code (tarsal or metatarsal bones, malunion of, or nonunion of) based on the VA C&P examination 4 months before separation, citing evidence of degenerative changes and pain with moderate symptoms.  The 10% rating under 5279 is the highest allowed under that code.  The higher 20% rating under the 5283 code requires demonstration of a moderately severe foot condition but Board members agree that this was not warranted in the absence of weight-bearing issues, incapacitating episodes or weakness.  Both NARSUM and C&P examinations recorded subjective pain as the only significant finding.  The Board determined that the evidence did not support a rating higher than 10% under any other applicable code.  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 chronic right foot pain condition.  

Left Foot Condition.   According to the STR and MEB NARSUM, the CI’s history of foot pain began during basic training.  Diagnostic imaging of the left foot in November 2007 showed mild degenerative changes of the metatarsophalangeal joint.  Conservative treatment did not result in improvement sufficient to allow unrestricted duty.  The MEB forwarded “bilateral foot pain” (specifically noting the left and right foot did not meet retention standards) for PEB adjudication.

The MEB NARSUM examination, dated 18 March 2008 (4 months before separation), documented a normal gait and foot appearance.  On examination, pain was noted over the sesamoid bone under the head of the first metatarsal, but the foot was otherwise normal and non-tender.  Range of motion (ROM) measurements, vascularity and sensation were also normal.  The examiner stated that the left foot was painful only when he [CI] walked “a lot” and that running precipitated the pain.  The MEB addendum, dated 5 May 2008, referenced a civilian podiatry assessment (in April 2008) of avascular necrosis of the left tibial sesamoid bone as the likely cause of the CI’s left foot pain.  The MEB examiner noted that radiograph interpretations documented no significant indication of avascular necrosis but could not rule in or out a formal diagnosis.  The examiner stated that the CI’s left foot had been stable for over a year, and that it was expected that he would have “long-term discomfort” with excessive activity.  

At the VA Compensation and Pension (C&P) examination on 7 April 2008 (4 months before separation), the CI reported left foot pain with weight bearing or “prolonged time on the foot” rated at 2/10, but no weakness, stiffness, swelling, or fatigability.   He did not take medications for pain and had no flare-ups; he did not use corrective shoes, inserts or braces.  Physical examination revealed pain with palpation of the left foot plantar surface but normal ROM.  There was no painful motion during toe movement and the CI was able to stand on his toes. The examiner noted no evidence of vascular compromise or abnormal weight bearing.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating using the analogous code 5099-5003 (arthritis, degenerative) citing foot pain preventing full foot function.  The VA assigned a 0% rating under the analogous 5099- 5024 (tenosynovitis) code citing normal toe ROM and no pain.  The Board noted the absence of weight-bearing issues, deformities, limitation of motion, or weakness, and that both NARSUM and C&P examinations recorded subjective pain as the only significant finding.  Members agreed that the evidence did not support a rating higher than 10% under any applicable code.  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 chronic left foot pain condition.  

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that anxiety disorder not otherwise specified (NOS) and insomnia due to stress were not unfitting.  The Board noted the S2 profile for the anxiety, however, no mental health condition was implicated in the commander’s statement or judged to fail retention standards.  Available STRs were silent for an insomnia condition.  However, case management notes in the months of March, April and May 2008 recorded the CI was able to achieve 5-6 hours of sleep and that anxiety symptoms had improved significantly.  There was no performance based evidence from the record that either condition significantly interfered with satisfactory duty performance.  After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the contended conditions and so no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the chronic right foot condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the chronic left foot condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended anxiety disorder NOS and insomnia due to stress conditions, the Board unanimously recommends no change from the PEB determinations as not unfitting.  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 20140405, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

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 XXXXXXXXXXXXXXXXXXXXXXX AR20160010518 (PD201401591)

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