RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02422
BRANCH OF SERVICE:  Army	BOARD DATE:  20150428
SEPARATION DATE:  20080702

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-3 (Infantry) medically separated for right and left foot conditions.  These conditions could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty or satisfy physical fitness standards.  He was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  The MEB forwarded to the Physical Evaluation Board (PEB):  “right plantar fasciitis,” “left plantar fasciitis” and “right second and third metatarsal stress fractures” as medically unacceptable IAW AR 40-501.  No other conditions were submitted by the MEB.  The PEB adjudicated “right foot healing stress fractures of the 2nd and 3rd metatarsals” and “left foot plantar fasciitis” as unfitting, rated 10% and 10%, citing criteria of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The CI made no appeals and was medically separated.

CI CONTENTION:  “Please consider old 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 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:

IPEB – Dated 20080612	VA* - (~3 Mos. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Foot Healing Stress Fractures	5284	10%	S/P Closed Stress Fractures…Right Foot	5283-5284	10%	20081029	
Left Foot Plantar Fasciitis	5399-5310	10%	Plantar Fasciitis, Achilles Tendonitis, and Pes Plans	5276-5284	10%	20081029	
Other x 0 (Not In Scope)	Other x 4	
RATING:  20%	RATING:  20%	
*Derived from VA Rating Decision (VARD) dated 20090107 (most proximate to date of separation [DOS]).

ANALYSIS SUMMARY:  The history and exams for the right and left foot conditions overlapped and are presented together.

Right and Left Foot Conditions:  The narrative summary (NARSUM) and treatment record noted the CI had mild asymptomatic pes planus (flat feet) on entry to the military (MEPS physical performed in September 2007).  In week five of basic training the CI had onset of bilateral foot pain following a sprinting exercise.  Conservative therapy including stretches, physical therapy, anti-inflammatory medications, arch support inserts, rest including soft shoes and crutches did not adequately resolve the bilateral foot pain.  Evaluations and imaging indicated right foot stress fractures (2nd and 3rd metatarsals-longer bones in front portion of foot) and bilateral plantar fasciitis with flat feet.  A treatment note (AHLTA – electronic medical record) the week prior to the NARSUM had noted bilateral pain with ankle motion.  At the MEB exam, the CI reported continued bilateral foot pain.  The MEB physical exam noted a normal gait with normal painless bilateral ankle and toe motion and no signs of ankle instability.  Fallen arches were noted and the CI had “tenderness on palpation along the bilateral plantar foot surfaces and right second and third metatarsals.”

At the VA Compensation and Pension exam performed 3 months after separation, the CI reported bilateral Achilles tendonitis, flat feet, plantar fasciitis, and stress fractures of metatarsal bones.  He had pain in his feet and lower legs with prolonged standing or activity and rest and medication (Motrin) provided relief.  He did not use arch supports by report.  Exams of the ankles demonstrated full normal range-of-motion without pain or decrease on repetitive motion.  There was no ankle weakness or instability.  Each foot had tenderness over the bottom of the foot (plantar surface) and over the Achilles (heels) with radiographs documenting bilateral posterior heel spurs.  Pes planus was not present on exam, but noted on X-rays as “mild pes planovalgus.”  

The Board directed attention to its rating recommendation based on the above evidence.  The primary disability codes considered were 5020 (Synovitis); 5276 (Flatfoot, acquired [pes planus]); 5283 (Tarsal, or metatarsal bones); 5284 (Foot injuries, other); and 5310 (Group X muscle function).  There was no single code that specifically aligned with the CI’s foot diagnoses and analogous coding IAW VASRD §4.20 (Analogous ratings) were discussed for each foot.  The complex interrelationships of the ankle joint, tendons (Achilles) and ligaments, heel pad, plantar fascia, and bones of the foot were not individually separable for rating.

Right Foot Healing Stress Fractures of the 2nd and 3rd Metatarsals … and Plantar Fasciitis.  The service PEB diagnoses for the right foot differed slightly from the VA diagnoses that also included pes planus and Achilles tendonitis.  The service treatment record (STR) supported the findings of pes planus and Achilles tendonitis of the right foot; however, this did not impact the rating level as regardless of the additional components of foot pathology, or the analogous coding used, there was insufficient evidence of “moderately severe” muscle injury, tarsal fractures or foot injury; or severe foot deformity from pes planus, for any rating higher than 10%.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends no change in the PEB disability rating for the right foot condition.

Left Foot Plantar Fasciitis.  The service PEB diagnoses for the left foot differed slightly from the VA diagnoses that also included metatarsal stress fractures, pes planus and Achilles tendonitis.  The STR supported the findings of pes planus and Achilles tendonitis of the left foot; however, there was no source imaging or document supporting the VA diagnosis of stress fractures in the left foot.  The PEB rated the left foot analogous to 5310 (Group X muscle function) citing “pain and loss of endurance (a cardinal sign of muscle injury)” and rating as moderate muscle disability; this was adjudged an acceptable rating schema IAW VASRD principles and VASRD §4.3 (reasonable doubt).  There was no avenue to a rating level higher than 10% as regardless of the additional components of foot pathology, or the analogous coding used, there was insufficient evidence of “moderately severe” muscle injury, tarsal fractures or foot injury; or severe foot deformity from pes planus.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends no change in the PEB disability rating for the left foot 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 right foot condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the left foot condition and IAW VASRD §4.71a and §4.73, 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 20140512 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, AR20150014444 (PD201402422)

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