RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-01674
BRANCH OF SERVICE:  AIR FORCE	BOARD DATE:  20150113
Separation Date:  20030228

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 stress fracture, left second metatarsal, symptomatic.  The condition could not be adequately rehabilitated to meet the physical requirements of her Air force Specialty or satisfy physical fitness standards. She was issued a temporary L4 profile and referred for a Medical Evaluation Board (MEB).  An Informal Physical Evaluation Board (PEB) initially found the CI “Fit for Duty” and she continued her rehabilitation.  The stress fracture, left second metatarsal, symptomatic condition, characterized as “stress fracture of left second metatarsal, still symptomatic” was again forwarded to the PEB IAW AFI 48-123.  The MEB also identified and forwarded one other condition.  The second Informal PEB adjudicated “stress fracture, left second metatarsal, symptomatic” as unfitting, rated 10% with likely application of Department of Defense Instruction (DoDI) 1332.39 and VA Schedule for Rating Disabilities (VASRD).  The remaining condition, asthma was determined to be a Category II condition (“Conditions that can be unfit, but not compensable or ratable”) and existing prior to service.  The CI made no appeals and was medically separated.

CI CONTENTION:  “veterans continues to receive tx – recent x-rays 2 mo - veteran experiences continued pain as a result of injury – employment is impacted by injury.” Her 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 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 IPEB – Dated 20030220	VA - (10 Mos. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Stress Fracture, Left Second Metatarsal, Symptomatic	5099-5022	10%	Stress Fracture of the Left 2nd Metatarsal	5283	 NSC*	20040422	
			Stress Changes, Left Foot	5283	NSC	20040422	
Asthma	CAT II	EPTS	Asthma	6602	NSC	20040422	
Other x0		
Combined:  10%	Combined:  NSC	
Derived from VA Rating Decision (VARD) dated 20040310 (most proximate to date of separation [DOS])
*Per VARD dated 20040719 – 5283-5279 rated 10%

ANALYSIS SUMMARY:  

Stress Fracture, Left Second Metatarsal, Symptomatic Condition.  The CI initially developed left knee pain after a fall during a physical conditioning run.  She underwent physical therapy (PT) and was placed in medical hold status.  A left foot X-ray demonstrated a 2nd metatarsal bone fracture.  The CI was given a temporary L4 Profile with specific restrictions of no walking without crutches, no running, PT or crouching.  The orthopedist noted physical exam findings of mild swelling left foot over the dorsal forefoot, tenderness to palpation (TTP) over 2nd and third metatarsals.  The examiner diagnosed left 2nd metatarsal shaft fracture and prescribed crutches in a hard sole shoe as tolerated for 3 weeks, narcotic pain medication and a 6-week profile.  Six weeks later, a repeat left foot X-ray showed a healing left 2nd metatarsal fracture.  The orthopedist noted recurrent left foot dorsum symptoms with physical exam findings of minimal edema and TTP over the healing fracture site.  A bone scan demonstrated an area of focal uptake in the left foot at the 2nd mid metatarsal, which was consistent with a stress fracture of the left 2nd metatarsal.  A repeat bilateral foot X-ray showed no change from the previous X-ray.  The CI was reevaluated by orthopedics and showed no improvement in left foot symptoms.  The MEB NARSUM exam, performed approximately 4 months prior to separation documented that the CI had chronic pain and recommended separation and possible re-enlistment after a 12-month rehabilitation.  There was no physical exam performed at this time.  A bilateral foot X-ray showed a healing left 2nd metatarsal stress fracture and a probable new stress fracture of the left 3rd metatarsal.  When the CI did not respond to a longer period of rehabilitation, a second MEB narrative summary exam was accomplished approximately 3 weeks prior to separation documented chronic left foot pain despite extended treatment.  There was no physical exam done at this time.  A bilateral foot X-ray was normal.  The examiner diagnosed a stress fracture of the left 2nd metatarsal and recommended separation.  The VA Compensation and Pension (C&P) exam 14 months after separation documented that the CI was employed as a bank teller and that her foot pain interfered with her activities of daily living, there was daily pain at 6-9/10 and increased with ambulation.  The physical exam findings were left mid-foot mild non-pitting edema and pain noted in the 2nd to 5th metatarsal shafts with palpation.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB coded the stress fracture, left second metatarsal, symptomatic condition as 5099 analogous to 5022 and rated at 10%.  The VA coded the stress fracture of the left 2nd metatarsal as 5283 (non-union or mal-union of the tarsal or metatarsal bones) and did not grant service-connection based on failure to show for her C&P exam.  Later, the CI underwent a VA C&P exam and the subsequent VARD dated 19 July 2004 changed the condition to bilateral feet pain with a history of metatarsal stress changes, coded as 5283 with 5279 (anterior metatarsalgia) and rated it 10% effective on 1 March 2003.  All exams proximate to separation showed painful left foot 2nd metatarsal with all activity.  The VASRD does not contain a code specific for stress fractures; therefore, analogous coding is appropriate.  The PEB used code 5022 which is rated under 5003 (degenerative arthritis) while to VA used code 5279.  The Board considered each coding and rating scheme and agreed that use of either code would result in a 10% rating for the left second metatarsal, as applied by the VA.  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 second metatarsal stress fracture 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 stress fracture, left second metatarsal, symptomatic 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 20140414, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

			
XXXXXXXXXXXXXXXXXXXX
President
DoD Physical Disability Board of Review

SAF/MRB
1500 West Perimeter Road, Suite 3700
Joint Base Andrews, MD  20762

Dear XXXXXXXXXXXXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Title 10 U.S.C. § 1554a), PDBR Case Number PD-2014-01674.

After careful consideration of your application and treatment records, the Physical Disability Board of Review determined that the rating assigned at the time of final disposition of your disability evaluation system processing was appropriate.  Accordingly, the Board recommended no re-characterization or modification of your separation.

	I have carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding and their conclusion that re-characterization of your separation is not warranted.  Accordingly, I accept their recommendation that your application be denied.

							Sincerely,

XXXXXXXXXXXXXXXXXXXX
Director
Air Force Review Boards Agency

Attachment:
Record of Proceedings