RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02568
BRANCH OF SERVICE: Army 	SEPARATION DATE:  20080208

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-2 (Trainee) medically separated for chronic right leg and foot pain.  The leg and foot could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty.  Her profile allowed for an alternate aerobic event to satisfy physical fitness standards.  She was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  The “chronic right leg pain and right foot pain secondary to old stress fractures,” was the only condition forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The Informal PEB adjudicated “chronic right leg pain and foot pain from old stress fractures” as unfitting, rated 10%, with application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  An administratively corrected PEB changed the disability description to “impairment of tibia and fibula with chronic right leg and foot pain from old stress fractures evaluated analogous to periostitis.”  The CI made no appeals and was medically separated. 

CI CONTENTION:  The CI contends for all conditions. The applicant’s 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:  

Admin Corr IPEB - Dated 20090326	VA* - (~9 Mos. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Impairment Of Tibia and Fibula with Crhonic Right Leg And Foot Pain From Old Stress Fractures	5299-5262	10%	Fracture of Tibia Bone (Right Leg)	5262	NSC	20081105	
			Residuals of Right Ankle Condition	5271	NSC	20081105	
Other MEB/PEB Conditions x 0 (Not In Scope)	Other x 1	
RATING:  10%	RATING:  NONE	
*Derived from VA Rating Decision (VARD) dated 20090126 (most proximate to date of separation [DOS]).  
ANALYSIS SUMMARY:  

Impairment of Tibia and Fibula with Crhonic Right Leg and Foot Pain from Old Stress Fractures.  The CI presented with right foot pain in February 2007.  X-rays performed 5 March 2007 were negative bony or soft tissue pathology.  A bone scan performed 18 April 2007 revealed an early, small stress fracture at the right distal tibia and stress changes in the left ankle and foot.  The CI was treated with crutch ambulation, physical therapy, and anti-inflammatory medication.  Radiographic re-evaluation dated 22 June 2007 demonstrated stable thickening of the bone (sclerosis) in the distal tibia consistent with a prior stress injury.  At a physical therapy evaluation dated 18 July 2007 that she was able to run 1/2 mile without pain and felt ready to complete the repelling wall to complete basic training.  She rated the hip and ankle pain 3/10.  The physical examination demonstrated a non-antalgic gait; 5/5 bilateral lower extremity strength, except for the right extensor hallucis longus (great toe flexion) which was 4/5; and decreased sensation and light touch at the lumbar 4 nerve distribution.  A diagnosis of healing right stress fracture was noted.   An orthopedic evaluation dated 22 October 2007 noted reports of right foot and ankle pain.  The examiner noted that the stress fracture was “almost completely healed on X-ray.”  The physical findings of tenderness to palpation at the distal tibia and normal ankle and foot examinations were noted.  The examiner opined that the continued pain from the healing right lower extremity stress fracture prevented return to duty.  At the narrative summary (NARSUM) examination the CI reported right leg and foot pain which worsened with prolonged standing, weather changes, and sleep position.  The pain during exacerbation was rated 7-8/10.  She used Excedrin and occasionally Skelaxin for pain relief.   The physical examination is documented in the chart below.  

At the VA Compensation and Pension (C&P) examination performed 9 months after separation, the CI reported right ankle pain with walking and running.  She used Motrin for pain.  The CI was employed as an operator.  The physical findings are documented in the chart below.  The examiner noted that decreased mobility due to right tibial pain impacted occupational activities.  The goniometric range-of-motion (ROM) evaluations in evidence which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below.

Right Ankle ROM
(Degrees)	MEB ~3 Mo. Pre-Sep
(20071127) 	VA C&P ~9 Mo. Post-Sep
(20081105) 	
Dorsiflexion (20 Normal)	12	15	
Plantar Flexion (45)	30	45	
Comment	Tibial tenderness to palpation, no ankle pain, 5/5 strength, no foot tenderness to palpation	Antalgic gait, painful ankle motion, no instability, no motor loss	
§4.71a Rating	10%	10%	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB combined the right leg and foot pain conditions under a single Service disability rating, analogous to 5262 (tibia, impairment of) and rated 10% for slight ankle disability.  IAW DoDI 6040.44 if the PEB combined adjudication is not compliant with the VASRD combined rating criteria, each condition subsumed under the single Service disability rating must be reasonably justified as separately unfitting in order to remain eligible for Service rating.  The Board’s initial charge in this case was directed at determining if the PEB’s combined adjudication was justified in lieu of separate ratings.  In this case the right lower extremity was profiled.  The right ankle and foot were considered to fail retention standards and implicated by the NARSUM.   Multiple treatment notes documented right ankle and foot stress fractures.  Members agreed that the ankle and foot were separately unfitting.  The Board then considered rating the conditions.  Multiple treatment notes documented ankle and foot pain with use and objective physical findings of painful motion.  Board members agreed that VASRD §4.59 (painful motion) and §4.40 (functional loss) criteria were met for a rating 10% for the right ankle, coded 5299-5262, and 10% for the right foot, coded 5279 (metatarsalgia).  

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 ankle condition condition, the Board unanimously agreed that it was separately unfitting and recommends a disability rating of 10%, coded 5299-5262 IAW VASRD §4.71a.  In the matter of the right foot condition, the Board unanimously agreed that it was separately unfitting and recommends a disability rating of 10%, coded 5279 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 her prior medical separation:  

CONDITION	VASRD CODE	RATING	
Right Ankle Pain 	5299-5262	10%	
Right Foot Pain	5279	10%	
RATING	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140526, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAMR-RB										

MEMORANDUM FOR Commander

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for XXXXXXXXXX, AR20160003817 (PD201402568)

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, accept the Board’s recommendation to modify the individual’s disability rating to 20% without re-characterization 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