RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02880
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20051016

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E4, Signal Support Systems Specialist, medically separated for “chronic right hip and sacroiliac pain” and “chronic left heel pain,” rated 10% and 10%, respectively, with a combined disability rating of 20%.

CI CONTENTION:  “Please consider 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.  It is limited to those conditions determined by the Physical Evaluation Board (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 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 Veterans Affairs Schedule for Rating Disabilities (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:  

SERVICE PEB - 20050610	VARD - 20060622	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Right Hip and Sacroiliac Pain	5236	10%	Right Hip Loss of Motion, Residual of Pelvic Fractures	5252-5010	10%	20051125	
Chronic Left Heel Pain	5284	10%	Left Foot and Ankle Loss of Motion, Residual of Calcaneal Fracture, Post-Operative, With Scar	5284-5271	10%		
			Left Foot and Toes Paresthesia Associated with Left Foot and Ankle Loss of Motion, Residual of Calcaneal Fracture, Post-Operative, With Scar	5279	10%		
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:    

Right Hip Condition.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM) the CI sustained injuries to the right pelvis and left calcaneus (heel bone) as a result of a 20-foot fall from a guard tower on 16 July 2004 while deployed and was evacuated to the United States where she initially underwent stabilization, anticoagulation, and pain control.  X-rays on 3 August 2004 demonstrated fractures of the superior and inferior pubic ramus on the right.  On the same day, the CI underwent surgery which included open treatment with internal fixation of the right pubic ramus fracture, percutaneous fixation of a right transforaminal sacral fracture, and temporary application and removal of a pelvic external fixator.  Initial rehabilitation was carried out while the CI was hospitalized and was continued while she was on convalescent leave.  A note dated 24 November 2004, indicated the CI was back to work and X-rays revealed a healed pelvic ring injury.  Further physical therapy was recommended for abdominal and pelvic strengthening.  At a physical therapy examination in March 2005, the CI noted difficulty lying on her right hip and had low back symptoms after sitting for long periods of time.  On examination there was a full range-of-motion (ROM) of the right hip with no increase in symptoms on motion.  Right hip strength was 4/5 with a positive FABER test (to evaluate pathology of the hip or the sacroiliac (SI) joint), negative hip scouring (test for hip dysfunction), and a negative straight leg raise (to determine nerve root irritation).   

At the MEB examination (recorded on DD Forms 2807 and 2808) dated March 2005, 7 months prior to separation, the CI reported she had surgery in 2004 for a fracture of the right pelvis that occurred when she fell off a tower when deployed and had lower back pain when she slept on her right side.  Physical examination showed that the CI had a full ROM of the right hip with 5/5 strength bilaterally and she was tender over the right SI joint.  Straight leg raises were negative bilaterally and her gait was normal.  In a follow-up visit on 22 August 2005, the CI had a painless ROM of the right hip; and, an appointment was set up for surgical hardware removal.  

The NARSUM examiner on 7 April 2005 indicated the CI’s gait was normal and active ROM of the right hip was full with no increase in symptoms.  Strength was 5/5 bilaterally and there was tenderness to palpation of the right hip with negative straight leg raise testing bilaterally.  The examiner noted that the CI’s pain from the pelvic ring fracture continued unabated from 2-3/10 (10 being the worst pain) at rest to 6/10 when exacerbated by prolonged standing, walking and stair climbing.  There was some relief with rest and medications.  An orthopedic report dated 20 April 2005, noted X-rays showing a healed pelvic fracture and a slight asymmetry with slightly shortened right hemipelvis.  

At the VA Compensation and Pension (C&P) examination on 25 November 2005, performed a month after separation, the CI reported an inability to sit in one position for longer than 15 minutes without developing pelvic pain, difficulty sleeping on the right side or back, and felt a popping sensation in both hips when walking.  She rarely took Percocet for pain and relied on NSAIDs for partial relief of pain.  On examination the CI’s posture was abnormal, which when she walked was slightly tilted to the right, but her gait was normal.  Increased pain on the right side was the major limiting factor with repetition.  Post-separation X-rays on 5 December 2005 revealed old internal fixation screws in the right pelvis and no significant right hip abnormality.

The 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 Hip (Thigh) ROM
(Degrees)	MEB ~6 Mo. Pre-Sep
	VA C&P ~1 Mo. Post-Sep
	
Flexion (125 Normal)	“Full”	90	
Extension (20)		25	
External Rotation (45)		70	
Abduction (0-45)		35	
Adduction (45)		25	
Comment	No increase in symptoms with ROM; tenderness to palpation of the right hip	Painful motion; increased pain with repetitive motion	
§4.71a Rating	PEB 10%	VA 10%	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating using code 5236 (sacroiliac injury and weakness) for chronic right hip and sacroiliac pain.  The VA assigned a 10% rating using code 5252-5010 (thigh limitation of flexion-arthritis due to trauma) for right hip loss of motion, residual of pelvic fractures.  The Board sought a route to a higher rating but was unable to do so in the absence of hip ankylosis, more limited extension or flexion, thigh impairment, a flail hip, or femur impairment.  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 fitness determination for the right hip condition.  

Left Heel Condition.  As noted above, the CI sustained injuries to the pelvis and left heel as a result of a fall off a guard tower and was evacuated home for definitive treatment.  X-rays of the left foot on 27 July 2004, demonstrated a comminuted fracture involving the calcaneus without any dislocation.  On 3 August 2004, the CI underwent an open reduction and internal fixation (ORIF) of her left calcaneus.  Thereafter she was non-weight bearing bed-to-chair for 6 weeks followed by non-weight bearing to her left lower extremity and touchdown weight bearing to the right lower extremity.  X-rays on 22 November 2004 indicated the hardware appeared to be intact in the left heel.  By 24 November 2004, she was back at work and had complaints about her ankle occasionally when she tried to wear shoes.  On examination she had no pain, but some stiffness with subtalar motion.  X-rays revealed a healed calcaneus fracture.  She was sent to physical therapy to help improve her ankle and subtalar ROM.  On 30 March 2005, the CI was evaluated for persistent numbness and tingling on the lateral plantar surface of the left foot post calcaneal fracture along with mild pain rated 3/10.  On examination her gait was normal and there was a scar hooking around the lateral malleolus then following along the length of the calcaneus.  Ankle motion was normal, but there was decreased sensation along the distribution of the lateral plantar nerve.  Strength was normal as was the left deep tendon reflex.  Electro-diagnostic studies were generally normal except for a partial palsy of the left lateral plantar sensory nerve.  In April 2005, she complained of some foot pain; the operative site of the left heel was well healed, but she had some stiffness in her subtalar joint.  Sensation was grossly intact and X-rays demonstrated a healed calcaneus fracture.  She was referred to physical therapy for ROM exercises and Achilles tendon stretching for tightness.  In August 2005, she indicated “she would like the plate from her left heel.” On examination she had a well healed scar and a somewhat tender Achilles tendon insertion.  A heel support was ordered.  Post-separation, X-rays revealed an old, internally fixed fracture of the left calcaneus with an otherwise negative left foot.  

At the MEB examination (recorded on DD Forms 2807 and 2808) dated March 2005, 7 months prior to separation, the CI reported a tingling feeling in her left foot and the three lateral toes with occasional numbness of the feet when sitting down to relax.  She further indicated her left foot became swollen from walking around all day and her left ankle stiffened up to where she was unable to walk without pain.  She speculated whether her ankle also stiffened when it was cold due to the plate in her foot.  The examiner noted tenderness to palpation at the left calcaneus and surgical scar, full left ankle ROM, a deep tendon reflex of 2+ [at the ankle], and that [the foot] was neurovascularly intact.  

The NARSUM examiner on 7 April 2005 noted tenderness to palpation of the left calcaneus and the surgical scar.  The neurovascular function was intact and her gait was normal.  The calcaneus was mobile and dorsiflexion ROM was within normal limits; plantar flexion was limited by 5 degrees from the right; inversion was 10 degrees; and eversion was 18 degrees.  The possible partial palsy of the left lateral plantar sensory nerve met retention standards.  The pain from her left calcaneal fracture continued unabated and when exacerbated, the pain in the foot heel rose to 9/10 and the pain was exacerbated by prolonged standing, walking and stair climbing.  Removal of the hardware was planned for later in the year.  

At the VA Compensation and Pension (C&P) examination dated 25 November 2005, performed a month after separation, the CI reported that at rest there was pain, weakness, stiffness; with walking there was swelling; and walking upstairs was difficult.  The ROMs of the left ankle are in the chart below.  The CI noted discomfort past 15 degrees with dorsiflexion and past 30 degrees for plantar flexion.

The 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.

Left Ankle ROM
(Degrees)	MEB ~7 Mo. Pre-Sep
	VA C&P ~1 Mo. Post-Sep
	
Dorsiflexion (20 Normal)	“WNL”	20	
Plantar Flexion (45)	“Limited by 5 degrees from Right”	35	
Comment	-	Discomfort on motion; pain and weakness with repetition	
§4.71a Rating	PEB 10%	VA 10%	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating using code 5284 (moderate foot injuries) for chronic left heel pain.  The VA assigned a 10% rating using code 5284-5271 (moderate foot injuries-ankle limited motion) for left foot and ankle loss of motion, residual calcaneal fracture, post-operative, with scar and a 10% rating using code 5279 (metatarsalgia) for left foot and toes paresthesia associated with left foot and ankle loss of motion, residual of calcaneal fracture, post-operative, with scar.  The Board sought a route to a higher rating and discussed the foot injury etiology, the surgery to correct the comminuted fracture, persistent pain when walking, and the postoperative retention of the plate, the sum of which precluded the use of boots and her inability to run and limited walking or stair climbing capability.  Therefore, consideration of a 20% rated for a moderately severe foot injury is not unreasonable.  However, there was no other route to a higher rating in the absence of acquired flatfoot, claw foot, or malunion or nonunion of the tarsal or metatarsal bones.  The Board discussed the VA rating for the mild sensory deficit of the left lateral foot and noted that the use of a peripheral nerve code requires a motor component in the form of weakness, which was not present in this case.  On the other hand, a sensory loss could be considered if the condition were unfitting; however there was insufficient medical evidence to support the notion that the mild sensory loss manifested by numbness and tingling interfered with wearing required equipment, although the CI had difficulty from wearing a boot, but that presumably emanated from the heel pain rather than from a minimal sensory deficit.  Furthermore, the left lateral plantar sensory nerve palsy met retention standards according to the NARSUM author.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 20% for the left heel pain condition.

BOARD FINDINGS:  In the matter of the right hip condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the left heel pain condition, the Board unanimously recommends a disability rating of 20% coded 5284 IAW VASRD §4.71a.  There were no other conditions within the Board’s scope of review for consideration.  The Board recommends that the CI’s prior determination be modified as follows; and, that the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective as of the date of her prior medical separation:  

CONDITION	VASRD CODE	RATING	
Right Hip 	5236	   10%	
Left Heel Pain	5284	20%	
COMBINED	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140515, 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 Ms. XXXXXXXXXX, AR20160007945  (PD201402880)

1.	Under the authority of Title 10, United States Code, section 1554(a), I approve the enclosed recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) pertaining to the individual named in the subject line above to re­ characterize the individual's separation as a permanent disability retirement with the combined disability rating of 30% effective the date of the individual's original medical separation for disability with severance pay.

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:

a.	Providing a correction to the individual's separation document showing that the individual was separated by reason of permanent disability retirement effective the date of the original medical separation for disability with severance pay.

b.	Providing orders showing that the individual was retired with permanent disability effective the date of the original medical separation for disability with severance pay.

c.	Adjusting pay and allowances accordingly.  Pay and allowance adjustment will account for recoupment of severance pay,] and payment of permanent retired pay at 30% effective the date of the original medical separation for disability with severance pay.

d.	Affording the individual the opportunity to elect Survivor Benefit Plan (SBP) and medical TRICARE retiree options.
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:
Enclosure

CF:
( ) DoD PDBR ( ) OVA