RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXX	CASE:  PD-2014-01921
BRANCH OF SERVICE:  Army	BOARD DATE:  20150219
Separation Date:  20041030

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an activated Reserve E-4 (Maintenance Supervisor) medically separated for a right foot fracture.  The right foot condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty.  He was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  The right foot condition, characterized as “right Lis franc injury status post (s/p) mid-foot fusion” was the only condition forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The Informal PEB adjudicated “right foot fracture (fx) dislocation with open reduction and fixation (ORIF)” as unfitting, rated 20% with likely application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The CI made no appeals and was medically separated.

CI CONTENTION:  “Please review all conditions.”

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 20040901	VA - (4.5 Mos. Pre-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Foot Fx Dislocation with Open Reduction and Fixation	5271	20%	S/P Fx of Right Foot, with Subsequent Fusion of the Metatarsal Bones…	5284	20%	20040607	
			Right Foot Neuropathy Associated with s/p Fx of Right Foot…	8520	10%	20040607	
Other x 0 (Not in Scope)	Other x 12	
Combined:  20%	Combined:  30%	
Derived from VA Rating Decision (VARD) dated 20040715 (most proximate to date of separation [DOS])

ANALYSIS SUMMARY:  

Right Foot Fx Dislocation with Open Reduction and Fixation Condition.  The CI sustained a right foot Lis franc (mid-foot) joint fracture on 24 March 2003 when he awoke from sleep, went to bathroom, felt dizzy, and tripped.  The CI was evaluated emergently by Orthopedics and an X-ray showed a fracture at the base of the second right metatarsal that was medially displaced.  The CI underwent closed reduction surgery on 25 March 2003.  Orthopedics saw the CI monthly throughout 2003 for complaints of swelling, pain and a necessary second surgery.  In May 2003, the Orthopedist noted tenderness to palpation (TTP), pain in the distal metatarsals and immobilized the foot for 3 weeks.  The primary care provider documented an antalgic gait, and ordered physical therapy (PT), foot elevation and a profile until 4 July 2003.  Three days later, the PT noted range-of-motion (ROM) of 30 degrees plantar flexion and 5 degrees dorsiflexion.  Orthopedics noted that the CI continued to have right foot pain and TTP at the dorsal aspect of the right foot with a non-weight bearing short leg cast.  The Orthopedist documented instability of the Lis franc fracture.  The CI underwent a mid-foot fusion with a titanium plate and four screws on 31 July 2003.  The Orthopedist ordered a walking boot to be used as tolerated.  In January 2004, the CI was removed from the walking boot and placed in regular shoes with a cane for ambulation.  The narrative summary (NARSUM) exam approximately 5 months prior to separation documented chronic right foot pain rated at 3/10 at rest and 4-5/10 with activity.  The CI was unable to stand for long periods of time or walk for long periods of time.  The examiner opined that the CI would no longer be able to run or walk for long periods of time and would only be able to stand for limited periods of time as tolerated.  

The VA Compensation and Pension (C&P) exam approximately 4 months prior to separation documented that the CI had very limited ROM, constant pain, required a cane to ambulate and could only tolerate shoes with Velcro.  He reported that he had exacerbations after standing for 10 minutes or walking too fast for a long distance.  The CI was limited to walking only one block without resting and complained about numbness over the dorsum of the foot where the plate was inserted.  When he had an exacerbation, there would be symptoms of increased cramps, pain, stiffness and weakness which would last 1 to 2 days.  The CI was unable to work as a psychiatric technician, as he was unable to run if needed.  The CI was given a permanent L3 profile; however, he was able to perform an alternate Army physical fitness test.  The VA C&P physical exam findings are summarized in the chart below.  The CI was sent to PT approximately 2 months prior to separation for ROM measurements requested by the PEB.  

There were three goniometric 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)	NARSUM ~5 Mos. Pre-Sep	VA C&P ~4 Mos. Pre-Sep	PT ~2 Mos. Pre-Sep	
Dorsiflexion (20 Normal)	10	5	9	
Plantar Flexion (45)	20	15	30	
Inversion 5-20	-	-	9	
Eversion 5-15	-	-	7	
Comment	Sensation intact except near surgical incisions; Normal pulses	Antalgic gait; Decreased sensation dorsum right foot; Normal reflexes	No painful motion	
§4.71a Rating	20%	30% (VA 20%)	20%-30%	
4.124 Rating	0%	10%	0%	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB coded the right foot Fx dislocation with ORIF condition as 5271 (limited motion of ankle) and rated at 20% consistent with “marked.”  The VA coded the s/p fx of right foot, with subsequent fusion of the metatarsal bones with significant loss of ROM, chronic pain-symptomatic condition as 5284 (other foot injuries) and rated at 20% consistent with “moderately severe.”  There is ample evidence in the service treatment record that the CI had limited dorsiflexion and plantar flexion.  Both the MEB NARSUM and VA C&P documented limited dorsiflexion of 5 to 10 degrees and plantar flexion limited to 20 to 15 degrees.  The Board noted that the CI’s profile allowed for performing an alternate fitness test consisting of swim or bike testing.  That information was adjudged to be more supportive of the “moderately severe” 20% rating criteria under code 5284.  The moderately severe rating under 5284 was the same as the “marked” 20% rating applied by the PEB under code 5271.  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 Fx dislocation with ORIF condition.

The Board next considered whether an additional rating could be recommended under a peripheral nerve code, as conferred by the VA, for the associated right foot neuropathy at separation.  Firm Board precedence requires a functional impairment linked to fitness to support a recommendation for addition of a peripheral nerve rating.  The sensory component in this case has no functional implications, and no motor weakness was in evidence.  There is thus no evidence of a separately ratable functional impairment (with fitness implications) from the residual radiculopathy; and, the Board cannot support a recommendation for an additional disability rating on this basis.

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 foot fracture dislocation with open reduction and fixation condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the right foot neuropathy, the Board unanimously recommends no additional disability rating.  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 20140425, 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, AR20150010457 (PD201401921)

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