RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02782
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20040910

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (Medical Specialist Trainee) medically separated for chronic low back and right ankle conditions.  The conditions could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty (MOS). She was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  The “mechanical low back pain,” “right ankle stress changes without fracture or ankle instability,” and “plantar fasciitis” conditions were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501, the plantar fasciitis as medically acceptable.  The Informal PEB (IPEB) adjudicated “chronic subjective low back pain” and “chronic pain, right ankle” as unfitting, rated 10% each, citing application of the US Army Physical Disability Agency (USAPDA) pain policy.  The remaining condition was determined to be not unfitting.  The CI made no appeals and was medically separated.  

CI CONTENTION:  The applicant requested that the Board consider all of her conditions.  Her 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 20040830	VA* - (~1 mo. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Subjective LBP	5299-5237	10%	Disc Bulging of L5-S1	5243	10%	20041019	
Chronic Pain, Right Ankle	5099-5003	10%	Right Ankle Strain	5271	10%	20041019	
Plantar Fasciitis	Not Unfitting	Left Plantar Fasciitis	5299-5284	0%	20041019	
		Right Plantar Fasciitis	5299-5284	0%	20041019	
Other MEB/PEB Conditions x 0 (Not In Scope)	Other x 6	
RATING:  20%	RATING:  30%	
*Derived from VA Rating Decision (VARD) dated 20050323 (most proximate to date of separation (DOS)).  

ANALYSIS SUMMARY:  

Chronic Subjective Low Back Pain.  The CI was first seen in March 2004 for a history of low back pain (LBP) for the previous month with occasional radiation to the right thigh.  A physical therapy appointment for her right ankle on 12 March 2004 noted that her gait and posture were normal.  An X-ray on 16 March 2004 was normal.  Treatment with duty restrictions, medications, and physical therapy (PT) was unsuccessful.  She was then issued a L3 profile and entered into the MEB process.  At the MEB examination, the CI reported that she had fallen onto her back in training.  The MEB physical exam noted mild limitation in range-of-motion (ROM) measurements with 5-/5 strength in the right lower extremity.  Signs of non-organic pain were absent and provocative testing of the nerve roots negative.  Heel to toe gait was normal.  The narrative summary (NARSUM) was the same day and noted that her gait was painful.  However, the toe-walk, heel-walk, and squat-walk were all without difficulty.  She had a normal neurological examination and her ROM exceeded VA normal values as charted below.  Tenderness was not present and spasm not documented.  An MRI on 24 June 2004 showed a diffuse disc bulge at L5-S1 without nerve root compromise.  At physical medicine on 28 July 2004, she was noted to have a slow gait with the use of a cane.  Multiple trigger points of a ligament between the pelvis and lumbar spine on the right were tender.  The neurological examination and electrodiagnostic testing were normal.  The VA Compensation and Pension (C&P) examination was performed on 19 October 2004, a month after separation.  The CI reported no time lost from work.  On examination, she had tenderness of the spine, but a normal gait and posture.  However, she did use a cane for walking.  The ROM was reduced as charted below.  Provocative testing for nerve root irritation was negative and the neurological examination normal.  Tenderness was present, but spasm not documented.  The goniometric 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.

Thoracolumbar ROM
(Degrees)	MEB ~3 Mo. Pre-Sep	NARSUM ~3 Mo. Pre-Sep	VA C&P ~1 Mo. Post-Sep	
Flexion (90 Normal)	90 (100)	90 (95)	70	
Combined (240)	195	240	170	
Comment	Paraspinal tenderness	No tenderness	Nml neurological examination and gait; tender	
§4.71a Rating	10%	0%	10%	

The Board directed its attention to its rating recommendation based on the above evidence.  The ROM and tenderness documented on the MEB and VA C&P examinations support a 10% rating for the back.  No route to a higher rating was found.  There is no evidence of an unfitting radiculopathy at separation.  The PEB rated the back at 10%, coded analogously as 5299-5237 (lumbosacral strain).  The VA also rated the back at 10%, coded 5243 (intervertebral disc syndrome).  Neither code provided a rating advantage over the other.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the back pain condition.  

Chronic Right Ankle Condition.  The CI was first seen for bilateral foot pain at a PT appointment on 22 August 2003 in week 7/9 of training.  She was noted to have a non-antalgic gait (normal) and full ROM.  She was treated with ice, compression, and elevation with a return to duty.  The next record in evidence is for her right ankle on 12 March 2004.  A bone scan on 20 February 2004 had shown an early stress fracture of the left shin bone and stress changes of the right ankle.  She reported right ankle burning with walking since an inversion injury the previous November.  Her gait, posture, and ROM were normal, but some laxity was noted with one maneuver to assess stability.  Her prognosis was thought to be good.  When seen in primary care on 29 April 2004, she was noted to be progressing, but to have poor stability.  The next month, she was thought to have improved sufficiently to resume training on 1 June 2004.  However, her pain persisted and she was entered into the MEB process.  At the MEB examination, the CI reported that she had fractured her feet in basic training.  The examiner noted full ROM, but tenderness to palpation.  The NARSUM noted a minimally antalgic gait (abnormal due to minimization of pain) with the ability to the toe-walk, heel-walk, and squat-walk without difficulty.  The ankle was neither swollen nor tender.  The ROM exceeded VA normal values by 5 degrees in dorsiflexion (toes up) and was less than the VA normal values in plantar flexion (toes down) by 10 degrees.  One test for stability was normal.  At the VA C&P examination the CI reported that she had stepped into a hole in November 2003 with swelling and pain on the outside of her ankle (consistent with a lateral sprain).  She continued to have pain with walking long distances, running, and lifting.  She used a cane as needed, but had not lost time from work.  The examination of her ankle was normal including gait and stability.  The goniometric 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)	NARSUM ~3 Mo. Pre-Sep	VA C&P ~1 Mo. Post-Sep	
Dorsiflexion (20 Normal)	25	20	
Plantar Flexion (45)	35	45	
Comment	Non tender	Normal examination	
§4.71a Rating	10%	0%	

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB rated the ankle at 10%, coded analogously as 5299-5003 (degenerative arthritis).  The VA also rated the ankle at 10%, coded 5271 (limited motion of the ankle).  The Board observed that the gait and ROM were normal or near normal on the examinations and that instability was not present.  No route to a higher rating was found under these or other coding options.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the right ankle condition.  

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that the bilateral plantar fasciitis condition was not unfitting.  The Board’s threshold for countering fitness determinations requires a preponderance of evidence, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.  The bilateral plantar fasciitis was not profiled or specifically implicated in the commander’s statement.  It was not judged to fail retention standards.  It was reviewed and considered by the Board.  There was no performance based evidence from the record that it significantly interfered with satisfactory duty performance.  After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination the plantar fasciitis condition and so no additional disability rating is recommended.  

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.  As discussed above, PEB reliance on the USAPDA pain policy for rating the back and ankle conditions was operant in this case and the conditions were adjudicated independently of that policy by this Board.  In the matter of the back and right ankle conditions and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended plantar fasciitis condition, the Board unanimously recommends no change from the PEB determinations as not unfitting.  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 20140527, 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 XXXXXXXXXX, AR20160003889 (PD2014-02782)

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:

Enclosure

CF: 
(  ) DoD PDBR
(  ) DVA