RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02540
BRANCH OF SERVICE:  Army	BOARD DATE:  20150402
SEPARATION DATE:  20060629

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-3 (Wheeled Vehicle Mechanic) medically separated for a left foot condition.  The condition 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 “painful subtalar joint arthritis left foot” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other conditions were submitted by the MEB.  The Informal PEB adjudicated “osteoarthritis of left subtalar joint” as unfitting, rated 0%, with likely application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The CI made no appeals and was medically separated.  

CI CONTENTION:  The CI requested that the Board review all of his conditions.  His 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 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 20060629	VA* - (~4 Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Osteoarthritis of Left Subtalar Joint	5003	0%	Left Foot Subtalar Joint	5284	20%	20061013	
Other MEB/PEB Conditions x 0 (Not In Scope)	Other x 2 	
RATING:  0%	RATING:  20%	
*Derived from VA Rating Decision (VARD) dated 20070414 (most proximate to date of separation (DOS)).  

ANALYSIS SUMMARY:  

Left Foot.  The record showed that the CI was initially seen for bilateral knee pain in November 2004, 4 months after accession.  The pain continued despite medications and duty limitation.  Consequently, a bone scan was done on 16 March 2005 which showed diffuse uptake in the knees but also intense uptake in the left talus (an ankle bone) consistent with a stress fracture.  He was seen in primary care a week later on 22 March 2005 and again noted bilateral knee pain since basic training, left greater than right.  He denied a fall or trauma.  No complaint was made of the ankle.  On examination, he was noted to have a normal arch which flattened with weight bearing and mild tenderness to the heel.  He was given duty restrictions and referred for orthotics.  On follow-up on 20 April 2005, the CI reported chronic knee and left heel pain since basic training despite the profile.  At the 21 June 2005 family practice visit, he reported left heel fracture in basic and advanced training with pain in formation.  He was referred to podiatry and issued a cam walker (for support).  On 25 July 2005, he reported to the podiatrist that his heel pain started in AIT (advanced infantry training) in October 2004.  He was tender on examination and placed in a walking cast.  He did not tolerate this and was placed back in a cam walker on 15 August 2005 and advised to remain non-weight bearing (NWB).  A CT scan of the left ankle and hind foot on 16 September 2005 showed a partial fusion of the joint between two ankle bones (the talus and calcaneus) on the left side with degenerative changes.  

The action officer observed that this is an indication of a chronic condition.  He was diagnosed with a left rear foot medial facet coalition (described in Wheeles orthopedics as a pre-existing condition which typically becomes symptomatic in the early teens which it ossifies (becomes bone like) and had surgery on 25 October 2005.  His post-operative course was unremarkable, but his pain persisted.  At a physical therapy (PT) follow up on 12 January 2006, the CI reported continued pain with standing, wearing boots, or walking over 50 feet.  He still had reduced range-of-motion (ROM) as well as swelling and bruising (residual from the surgery).  He was seen in podiatry on 15 February 2006 and reported continued pain.  A fusion of the joint, which had been discussed as a possible outcome prior to the operation in October 2005, was recommended, but declined.  The CI wished to pursue MEB and then surgery after separation.  X-rays showed good bony alignment after the surgery.  A second opinion was accomplished on 12 April 2006 and fusion again recommended and again declined, preferring to have this done by the VA back at his home of record after separation.  At the MEB examination on 13 March 2006, over 4 months after surgery and three months prior to separation, the CI reported that he could not stand for long periods or do long distance walking.  The MEB examiner recorded limited motion in all planes secondary to pain.  The narrative summary was dated 20 April 2006, 6 months after surgery and 2 months prior to separation.  On examination, the CI had increased pain with motion and was limited less than ten degrees for the sub-talar joint.  Dorsi- and plantar flexion (toes up and down, respectively) were also painful, but the range not recorded.  

At the VA Compensation and Pension (C&P) examination performed on 13 October 2006, just under 4 months after separation and a year after the surgery, the CI reported that he was taking no medications for the foot condition and did not use an assistive device.  He could stand for 30 minutes and walk 100 yards.  He stated that the ankle pain began while in AIT between October 2004 and February 2005.  On examination, he was noted to be obese weighing 210 pounds and 65 inches in height.  He reported a 50-pound weight gain the previous year.  The ROM was normal and symmetric with the unaffected right ankle.  There was no limitation with repetition.  His gait and posture were normal, but he was unable to heel walk secondary to pain and could not place his full weight on his left heel.  The Board noted the inconsistency of these findings in the setting of a normal gait.  

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB rated the right ankle condition at 0% using the code 5003 (degenerative arthritis).  The VA rated the ankle at 20% using the code 5284 (other injuries of the foot) and noted that the symptoms reported by the CI corresponded with a severe disability.  The Board observed though that the CI had a normal gait even in the face of a 50-pound weight gain and a normal ROM.  The objective findings are more consistent with a moderate level of disability.  The Board considered the coding options 5283 (malunion of the tarsal bone) and 5284, but neither offered a rating advantage to the CI over the 10% supported under 5003 for either limited or painful motion.  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 left ankle condition retaining the 5003 code.  

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 XX condition, the Board unanimously recommends a disability rating of 10%, coded 5003 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	
Osteoarthritis of the Left Subtalar Joint… 	5003	10%	
COMBINED	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140507, 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 XXXXXXXXXXXXXXXXXX, AR20150019020 (PD201402540)

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:

CF: 
(  ) DoD PDBR
(  ) DVA