RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXX	CASE:  PD-2014-02441
BRANCH OF SERVICE:  Army	BOARD DATE:  20150122
SEPARATION DATE:  20060914

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-2 (Animal Care Specialist) medically separated for bilateral foot pain.  This condition could not be adequately rehabilitated to meet the requirements of his Military Occupational Specialty or physical fitness standards, so he was issued a permanent L3 profile.  The “severe pes planus with stress reactions to the left foot” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other condition was submitted by the MEB.  The informal PEB adjudicated “chronic bilateral foot pain (left greater than right)…only left foot…service aggravated…” as unfitting, rated 0%, with likely application of the VA Schedule for Rating Disabilities (VASRD).  The CI made no appeals and was medically separated.

CI CONTENTION:  “Please consider 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:

PEB – Dated 20060823	VA* - (~28 Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Bilateral Foot Pain…	5022	0%	Pes Planus…Left Foot…	5276	20%	20090122	
Other x 0 	Other x 3	
RATING:  0%	RATING:  20%	
*Derived from VA Rating Decision (VARD) dated 20090313 (most proximate to date of separation (DOS)).

ANALYSIS SUMMARY:  The Board acknowledges that the original VA Compensation and Pension (C&P) examination was not available in the evidence before it.  The missing evidence will be referenced below in relevant context; and, it is not suspected that the missing evidence would significantly alter the Board’s recommendations.

Bilateral Foot Pain.  Other than disability related summary documents, the service treatment record (STR) contained a single clinical encounter by Podiatry (April 2006) whereby the CI’s chief complaint was left mid-foot pain.  Without direct trauma, his symptoms began in basic military training.  A bone scan revealed left mid-foot stress fractures.  Summary documents noted prior treatment included crutches, orthotic walker, casting, and rehabilitation; all of which were unsuccessful at resolving his painful symptoms.  The CI’s military entrance examination on 20 December 2005 identified bilateral “severe asymptomatic pes planus” (flat feet), applied no associated profiles, and required no waivers.  At the 20 June 2006 narrative summary (NARSUM) examination (3 months prior to separation) the CI endorsed difficulty running, jumping, marching, and completing his military duty due to left foot and ankle pain.  The physical examination (PE) revealed severe pes planus with tenderness present over the left mid-foot and ankle.  Left ankle range-of-motion (ROM) was decreased at 0 degrees dorsiflexion (normal: 20 degrees); plantar flexion was not documented.  X-rays noted “stress reaction” in the left foot.  The diagnosis was listed as “severe pes planus with stress reactions to the left foot.”  The C&P examination that the VA based its 20% rating was nearly 30 months remote from separation and thus its probative value for this Boards’ recommendation is moot.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB plainly indicated that the CI’s pes planus condition was present on his entrance examination and that only the left foot was permanently service aggravated.  Board members remained unsure of the PEB’s bilateral foot pain diagnosis when there was no evidence of right-sided pathology other than the pre-existing pes planus.  The NARSUM and STR podiatry document strictly addressed left foot pathology with abnormal PE and radiographic findings.

The Board first considered if the combined bilateral foot rating, as per the PEB approach, was most appropriate in considering separate fitness assessments.  In this particular case, abnormal pathology of the right foot (post-service entry) was never in evidence and therefore, not implicated as a separately unfitting condition and thus ineligible for rating.  The Board next acknowledged and agreed that the left foot condition was permanently aggravated by military service.  Severe pes planus is a condition with a well-recognized predilection for lifetime podiatric problems to include the development of stress fractures when subjected to increased activity.  The Board agreed that the onset of such activity (marching, running, and jumping) as part of basic training, indeed was an aggravating factor and or etiologic cause of the CI’s left foot stress fractures.

The Board then considered various coding options for the PEB’s bilateral foot condition.  The PEB’s coding choice of code 5022 (periostitis) which defaults to code 5003 (arthritis, degenerative) is often utilized in the setting of stress fractures or stress reactions and was appropriately utilized in this case.  The limited ankle ROM of 0 degrees dorsiflexion was supported under code 5271 (ankle; limited motion) at either 10% (moderate) or 20% (marked) impairment.  Members agreed that absent further directional ROM, the impairment level was best described as “moderate” connoting 10%.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% for the bilateral 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 bilateral foot condition, the Board unanimously recommends a disability rating of 10%, coded 5271 IAW VASRD §4.71a.  There were no other conditions within the Board’s scope of review for consideration.

RECOMMENDATION:  The Board recommends that the CI’s prior determination be modified as follows, effective as of the date of his prior medical separation:

CONDITION	VASRD CODE	RATING	
Chronic Bilateral Foot Pain 	5721	10%	
COMBINED	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140514, 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, AR20150010624 (PD201402441)

1.  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 to modify the individual’s disability rating to 10% without recharacterization of the individual’s separation.  This decision is final.  

2.  I direct that all the Department of the Army records of the individual concerned be corrected accordingly no later than 120 days from the date of this memorandum.   

3.  I request that a copy of the corrections and any related correspondence be provided to the individual concerned, counsel (if any), any Members of Congress who have shown interest, and to the Army Review Boards Agency with a copy of this memorandum without enclosures.

 BY ORDER OF THE SECRETARY OF THE ARMY:

Encl		     XXXXXXXXXXXXXXX
			     Deputy Assistant Secretary of the Army
			         (Review Boards)

CF: 
(  ) DoD PDBR
(  ) DVA