RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02445
BRANCH OF SERVICE:  Army 	BOARD DATE:  20150528
SEPARATION DATE:  20071030

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-2 (Light Wheel Vehicle Mechanic) medically separated for flat feet and a right ankle injury.  These conditions 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).  “Chronic bilateral foot pain secondary to pes planus,” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other condition was submitted by the MEB.  The Informal PEB adjudicated “stress reaction/overuse injury to right foot and ankle” and “pes planus, left foot” as unfitting, rated 0% and existed prior to service (EPTS) without permanent service aggravation respectively, with likely application of the Veterans Affairs 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:

 IPEB – Dated 20070924	VA* - (~3 Mos. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Stress Reaction/Overuse Injury to the Right Foot and Ankle…	5022	0%	Stress Reaction/Overuse Injury, Right foot and Ankle	5022-5271	20%	20080206	
Pes Planus, Left Foot…	5299-5276	EPTS	Bilateral Pes Planus…	5276	NSC	20080206	
Other MEB/PEB Conditions x 0 (Not in Scope)	Other x 1	
RATING:  0%	RATING:  20%	
*Derived from VA Rating Decision (VARD) dated 20080725 (most proximate to date of separation [DOS]).

ANALYSIS SUMMARY:
Pes Planus, Left Foot Pain with Persistent Pain.  On 26 October 2006 treatment records evidenced a week’s history of left foot pain with weight bearing and physical findings of left foot swelling, tenderness to palpation, and pain with motion.  X-ray evaluation was negative for fractures.  The CI was treated with crutch ambulation and physical therapy (PT) without resolution of the pain.  A bone scan dated 4 December 2006 demonstrated bilateral forefoot overuse changes without stress fractures.  The CI was diagnosed with overuse syndrome.  At a follow-up visit dated 8 January 2007, the examiner documented reports of left foot pain which worsened with standing and jumping.  The physical findings of left foot swelling and a normal gait were noted.  A diagnosis of metatarsalgia (foot pain) was rendered.  At a podiatry evaluation dated 12 February 2007, the CI reported left foot pain with weight bearing and swelling at the arch and top of the foot.  The pain was worse in the morning and progressed to swelling through the day.  The CI reported that the cam-walker (a boot that provides extra support to the foot and ankle) helped with the pain.  A physical finding of pes planus (flat foot) was noted.  Diagnoses of plantar fasciitis (inflammation of the lining of the foot) and flat foot were rendered.  The examiner opined that the flat foot condition EPTS.  The narrative summary (NARSUM) noted severe bilateral foot pain secondary to pes planus which was not relieved by activity limiting profiles or pain medication.  Physical findings were a normal gait, tenderness to palpation, and pain with motion.  The VA Compensation and Pension (C&P) examination performed 3 months after separation was not on file; however, it was referenced in a VARD.  The VASRD noted that the CI did not submit evidence of permanent aggravation of the left foot pain due to Service.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB adjudicated the left foot pain secondary to pes planus as unfitting, EPTS, and not permanently aggravated beyond the natural progression of the disease.  The Board noted there was no evidence that the pes planus was a result of a traumatic event; therefore it was reasonable to infer that this was a congenital abnormality that EPTS.  The Board then considered whether there was evidence that the condition was permanently aggravated.  Radiographic evaluations demonstrated evidence of left foot overuse, but no evidence of stress injury or stress fractures.  The left foot pain was documented as decreased when not wearing boots and with use of a cam-walker.  Board members agreed that the evidence does not support that the left pes planus condition was permanently aggravated by service.  Considering the totality of the evidence and mindful of VASRD §4.3 (reasonable doubt), members agreed that the PEB’s EPTS (without permanent service aggravation) determination was appropriate in this case.

Stress Reaction/Overuse Injury of Right Foot and Ankle.  A primary care note dated 4 December 2006 documented reports of bilateral ankle and foot pain.  On physical examination there was swelling of the right ankle, bilateral tenderness to palpation at the top of the foot (navicular area), but no pain or limitation of ankle motion.  A bone scan performed the same day revealed stress injury at the right inner ankle (anterior medial malleolus).  A diagnosis of compression arthralgia of the ankle and foot (bone pain due to impact activities) was rendered.  The CI presented to the emergency department on 1 January 2006 with a month long history of right foot pain after an injury.  X-rays demonstrated a possible subacute calcaneal avulsion fracture.  The CI continued to report right foot and ankle pain after trials of PT, activity modification, and pain medication.  The NARSUM noted severe bilateral foot pain secondary to pes planus which was not relieved by activity limiting profiles or pain medication.  Physical findings were tenderness to palpation of the tarsometatarsal joints (mid-foot) and instep, and pain with foot motion.  The ankle examination was without evidence of pain, limitation of motion, or instability.  The VA C&P examination performed 3 months after separation was not on file; however, it was referenced in a VARD.  The VASRD noted that the CI had ankle limitation of motion to 10 degrees of dorsiflexion (normal 20 degrees)due to pain.  There was further limitation with repetition of motion.
The Board directed attention to its rating recommendation based on the above evidence.  The PEB adjudicated the “stress reaction/overuse to right foot and ankle” as unfitting, rated at 0%, coded 5022 (Periostitis), for full ankle range-of-motion.   The VA rated the condition at 20%, coded 5022-5271 (Periostitis-ankle limitation of motion), for limitation of motion and functional loss.  The Board considered if the ankle and foot could be de-coupled and reasonably justified as separately unfitting.  Board members agreed that given the anatomical location of the pain at the junction ankle-foot complex, it would be speculative to attempt to separate the functional impact.  Board members agreed that pain at the ankle-foot junction produced a single function impairment resulting in the inability to wear boots and perform impact activities associated military service; therefore the ankle and foot could not be decoupled as separately unfitting conditions.  The Board then considered whether the evidence supported a rating higher than 0%.  Multiple treatment notes and the NARSUM examination documented right foot pain with motion and reports of pain with use.  Radiographic evaluation demonstrated right foot overuse and right ankle stress injury.  Board members agreed that the evidence supports a 10% rating IAW VASRD §4.40 functional loss.  There was no pre-separation evidence of ankle limitation of motion, tarsal malunion, or moderately severe foot injury for a higher rating.  After due deliberation, considering all of the evidence, being mindful of VASRD §4.3 (reasonable doubt), and IAW VASRD §4.40, the Board recommends a disability rating of 10% for the “stress reaction/overuse to right foot and ankle” 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 reaction/overuse to right foot and ankle” condition, the Board unanimously recommends a disability rating of 10%, coded 5022 IAW VASRD §4.71a.  In the matter of the left foot pes planus condition, 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 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	
Stress reaction/overuse to right foot and ankle	5022	10%	
RATING	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140517, 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, AR20150014431 (PD201402445)

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						     

CF: 
(  ) DoD PDBR
(  ) DVA