RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02949
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20040407

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SPC/E-4 (77F10/Petroleum Supply Specialist) medically separated for mechanical low back pain, bilateral knee pain and bilateral foot pain, rated at 10%, 0% and 0%, respectively, with a combined disability rating of 10%.

CI CONTENTION:  “Please consider all conditions”  

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44.  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 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: 

IPEB – Dated 20040203	VA* - (~3 Mos. Post-Separation) 	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Mechanical Low Back Pain…	5237	10%	Mechanical Low Back Pain	5237	0%	20040622	
Bilateral Knee Pain… 	5099-5003	0%	Bilateral Knee Condition	NSC	20040622	
Bilateral Foot Pain…	5099-5003	0%	Pes Planus	5276	0%	20040622	
Other x 0 (Not In Scope)	Other x 0	
RATING:  10%	RATING:  0%	
*Derived from VA Rating Decision (VARD) dated 20041026 (most proximate to date of separation (DOS)).  

ANALYSIS SUMMARY:  The PEB combined the left knee and right knee conditions as a single unfitting condition, and the left foot and right foot conditions as a single unfitting condition and coded both bilateral conditions 5099-5003 and rated 0%, citing slight/intermittent pain for each condition.  The PEB relied on the USAPDA pain policy for not applying separately compensable VASRD codes.  The Board must apply separate codes and ratings in its recommendations if compensable ratings for each condition are achieved IAW VASRD rating guidelines.  If the Board judges that two or more separate ratings are warranted in such cases, however, it must satisfy the requirement that each ‘unbundled’ condition was unfitting in and of itself.  Thus the Board must exercise the prerogative of separate fitness recommendations for the knee conditions and the foot conditions, with the caveat that its recommendations may not produce a lower combined rating than that of the PEB.  

Low Back Pain Condition.  The narrative summary (NARSUM) notes the CI had a gradual onset of symptoms, including low back pain (LBP), bilateral knee pain and bilateral foot pain, without a history of specific trauma.  Notes in the service treatment record (STR) indicated that beginning in January 2003, the CI was being treated for foot problems with bilateral pes planus (PP) and plantar fasciitis (PF), thought to be contributing to LBP and knee pain.  Prior to January 2003, there was a single treatment note for a back muscle strain incurred while playing basketball on 23 February 2002 treated with a temporary profile and over-the-counter medication.  There was no indication in the record that any residual problems resulted from this back strain.  At a physical therapy (PT) visit on 9 July 2003, the CI reported recent onset of LBP and the therapist noted the CI had been on crutches for three weeks, which had been provided for his foot pain addressed below.  Orthopedic evaluation on 7 August 2003 noted tenderness to palpation (TTP) of the lower lumbar spine.  Lumbar spine X-rays were normal.  Strength, sensation, and reflexes of the lower extremities (LEs) were normal and straight leg raise testing (SLR) was negative

At the MEB exam on 18 December 2003, 4 months before separation, the CI reported LBP.  The MEB physical exam noted TTP of the low back region, without bony deformity or muscle spasm.  Strength, sensation, and reflexes of the LEs were normal, with negative SLR.  Physical therapy measured range-of-motion (ROM) on 20 November 2003 was flexion of 40, 40, and 43 degrees (normal 90) and combined ROM of 135 degrees (normal 240).

At the VA Compensation and Pension (C&P) General exam performed 22 June 2004, 3 months after separation, the CI reported LBP three or four times per week, worse in the morning, but sometimes aggravated by activity.  He reported daily use of anti-inflammatory medication and intermittent use of the back brace, without significant benefit.  The VA examiner noted the CI did not have any weakness or “neuropathy,” and did not use a cane or crutches.  On exam there was normal posture and gait, with “completely normal upper and lower extremity strength and normal thoracolumbar range of motion (ROM)” with no sensory deficits.  The VA examiner indicated that an orthopedic C&P exam was pending for further evaluation of the back.  The original VA Rating Decision noted that the CI had not attended a scheduled orthopedic examination on 16 October 2004.

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB rated the low back condition 10%, coded 5237 (lumbosacral strain).  The VA rated the back condition 0%, noting the CI did not attend a scheduled VA exam for the back.  The evidence at the MEB exam noted a decreased forward flexion (FF) of the TL spine consistent with a 20% rating according to current VASRD rules for rating the spine in effect on the date of separation for FF of the TL spine of “greater than 30 degrees and not greater than 60 degrees,” but at the C&P exam the CI reported intermittent LBP and the exam noted normal TL ROM.  The Board considered that there was no documentation in record of a significant injury to the back, evidence of degenerative disc or joint disease of the spine (diagnosis or noted on imaging), or evidence that the motion of the TL spine was permanently or frequently limited due to muscle spasm or pain flare-ups.  The Board concluded from the evidence that the disability due to the back condition was due to pain, with variable ROM noted and supports a 10% rating with consideration of VASRD §4.59 (Painful motion) and §4.40 (Functional loss).  After due deliberation in consideration of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the low back condition.  

Bilateral Knee Condition.  The narrative summary (NARSUM) notes the CI had onset of back, knee and foot symptoms in January 2003 as noted above, which developed gradually without a history of specific trauma.  Notes in the STR indicated that the CI was being treated for foot problems with PP and PF, thought to be contributing to LBP and knee pain.  In early 2003 the CI was treated for left knee and shin pain increased by running.  Exams noted TTP of the knee and full ROM with crepitus.  At a primary care (PC) evaluation on 28 May 2003 the CI reported bilateral knee pain and the exam noted right greater than left knee crepitus and bilateral PP.  A PC exam on 15 July 2003 for bilateral arch and knee pain noted that there was full ROM of the knees, but pressure on the bottom of the foot caused pain and at a PC follow-up visit on 4 August 2003 the CI reported pain radiated from the arches of his feet to the inner aspect of the patella.  At an orthopedic evaluation on 7 August 2003 the knee exam, which did not indicate if for one or both knees, was normal with full ROM and no instability or evidence of cartilage injury.  

At the MEB exam 18 December 2003, 4 months before separation, the CI reported bilateral knee pain.  The MEB physical exam noted TTP of the joint lines, without crepitus, and an otherwise normal exam of the bilateral knees.  Physical therapy measured ROM 20 November 2003 showed extension-flexion of the right knee of 0–120, 0–125, 0-125 degrees (normal 0-140) and of the left knee of 0-130, 2-130, 2-130.  The NARSUM listed bilateral knee pain, without a specific diagnosis for either knee.

At the VA Compensation and Pension (C&P) General exam performed three months after separation, the CI reported knee problems secondary to his foot problems.  He reported knee pain once per week of variable duration, with no specific aggravating or alleviating factors.  The C&P examiner noted the knee pain was secondary to bilateral pes planus.  Exam of the LEs was normal as noted above with normal strength and sensation and no swelling.  The knees were not specifically examined.  As noted above, an orthopedic C&P exam was pending, which the CI did not attend.  

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral knee condition 0%, coded 5099-5003, rated IAW the USAPDA pain policy for a pain rating of slight. intermittent.  The VA rated did not service connect the bilateral knee condition.  As noted above, the CI failed to report to a scheduled VA C&P exam for the knees.  The Board first attempted to unbundle the bilateral knee conditions and determine if both the right and left knee conditions remained reasonably justified as separately unfitting when separated from the PEB’s combined adjudication.  The Board noted that both knees were addressed in treatment notes in the STR; the bilateral knee condition was profiled; and, the commander’s statement referenced “knees” as preventing the CI from “meeting his MOS physical requirements”.  The Board readily agreed that each knee was reasonably justified as unfitting and therefore eligible for service rating.  The medical evidence was presented in all exams for both knees, with no differences between them noted.  The Board considered that no specific diagnosis of the knees was provided at either the MEB or C&P exam and the evidence in the STR indicates that knee pain was secondary to the foot conditions.  Shortly after separation at the C&P exam the CI reported non-specific knee pain once per week and noted no specific aggravating factors.  The Board determined that neither the right knee or the left knee met greater than a 0% rating IAW VASRD §4.71a because there was no evidence of degenerative arthritis, limited ROM that met the threshold for a 10% rating based on ROM alone, instability, cartilage injury, or impairment of the tibia or fibula.  Additionally, within 3 months after separation, there was no evidence for either knee that pain with use persisted following separation from the military lifestyle and subsequent improvement in the foot pain.  Members agreed that the evidence supports a 0% rating for each of the right and left knees and that no higher evaluation was supported, including with consideration of §4.59 and §4.40.  Thus, having unbundled the bilateral knee condition the Board found it resulted in no ratings benefit to the CI and also noted that PEB reliance on the USAPDA pain policy was not detrimental to achieving the highest rating and therefore, no change to the PEB coding choice is recommended.  After due deliberation in consideration of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the bilateral knee condition.  

Bilateral Foot Condition.  The narrative summary (NARSUM) notes the CI had onset of symptoms as noted above, including bilateral foot pain in January 2003, which developed gradually without a history of specific trauma.  Notes in the STR indicated that the CI was diagnosed with bilateral PP and PF.  The CI’s military enlistment physical July 1998 noted the feet were asymptomatic, with normal arches.  Exams noted no swelling, bruising, or callosities, with full ROM, but pain with movement and weight bearing, and hyperpronation.  A PT note 9 July 2003 indicated the CI had been using crutches for the last three weeks due to the foot pain.  The CI was unable to tolerate arch supports and was referred to a civilian podiatrist.  A letter from the civilian podiatrist 30 July 2003 indicated the CI had a “chronic plantar fasciitis both secondary to severe flatfoot deformity” and was not helped by arch supports.  At a PC exam 4 August 2003 the CI reported pain the radiated from the arches of his feet to the inside of both knees.  The exam noted full ROM with TTP of the middle of the tibia bilaterally.  Bilateral foot X-rays 7 August 2003 were normal.  Orthopedic evaluation 7 August 2003 noted the CI was still ambulating with crutches.  Bilateral foot exam noted “mild” bilateral PP and was otherwise normal, with no TTP and full ROM noted.  A follow-up evaluation with the civilian podiatrist 21 August 2003 noted an antalgic gait.  There was TTP of the bottom of the foot, without swelling.  Weakness of tibialis posterior tendons (muscle/tendons support the medial arch of the foot) was noted, with excessive pronation of the feet.  The podiatrist recommended that the CI not continue in the military, but did not recommend surgery, though he noted the CI could pursue surgical treatment if desired.

At the MEB exam the CI reported constant bilateral foot pain aggravated by prolonged standing or impact activities.  He reported he could walk up to a mile or bicycle for up to an hour before having to stop due to pain.  The MEB physical exam of both feet noted full ROM, with TTP of the bottom of the foot.  Bilateral foot X-rays were normal except for an “obvious pes planus deformity”.  

At the VA Compensation and Pension (C&P) exam performed 3 months after separation, the CI reported foot pain 2-3 times per week, aggravated by weight bearing activities and improved by rest.  The exam noted that the CI had normal posture and gait and was walking without assistance.  Exam of the LEs was normal as noted above with normal strength and sensation and no swelling.  The feet were not specifically examined, but the VA examiner noted an orthopedic C&P exam was pending, which, as previously noted, the CI did not attend.  

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral foot pain 0%, coded 5099-5003 according to the USAPDA pain policy for a pain rating of slight, intermittent.  The PEB DD Form 199 noted that the CI had PP on exam, but normal arches noted on his enlistment physical.  The VA rated PP 0%, coded 5276 (acquired flatfoot).  The Board first attempted to unbundle the bilateral foot condition and determine if both the right and left foot conditions remained reasonably justified as unfitting when separated from the PEB’s combined adjudication.  The Board noted that both feet were addressed in treatment notes in the STR; the bilateral foot condition was profiled; and, the commander’s statement referenced “feet” as preventing the CI from “meeting his MOS physical requirements”.  The Board readily agreed that each foot condition was reasonably justified as unfitting and therefore eligible for service rating.  The Board first reviewed the VASRD §4.71a (musculoskeletal conditions) rating criteria of 5276 and agreed that the right and left foot conditions, though recommended as separately unfitting by the Board, met the 5276 10% rating for foot symptoms not relieved by orthotics, whether unilateral or bilateral, but a higher rating for either or both feet was not supported because there was no evidence of “marked deformity” or indication of “swelling on use” and “characteristic callosities” of either foot.  The civilian podiatrist referred to the flatfoot deformity as “severe”, but the service orthopedic specialist described it as “mild” pes planus; foot X-rays were read as normal by the radiologist, with no characteristic radiologic findings of severe flatfoot, or even flatfoot, noted; and, there was no documentation of swelling, bruising, callosities, or spasm or misalignment of the Achilles tendon at any exam in record.  

The Board next reviewed to see if individual rating of the left and right foot conditions IAW VASRD §4.73 coded as 5399-5310 (muscle injuries), an analogous code for PF, resulted in a higher evaluation for either or both feet.  Members noted that the rating criteria for 5310 are subjective with 0% for ‘slight,’ 10% for ‘moderate,’ 20% for ‘moderately severe’ and 30% for ‘severe’ muscle injury.  The Board reviewed that when coding the disability due to PF analogously as 5310, the discrimination between the ‘slight’ and ‘moderate’ characterizations depends on the presence of at least one cardinal sign or symptom of muscle injury specified as “loss of power, weakness, lowered threshold of fatigue, fatigue-pain, impairment of coordination and uncertainty of movement” for ‘moderate’, as opposed to none for ‘slight’.  There Board noted there was no distinction made between the right and left foot by symptom report or objective findings at evaluations in the STR or at the MEB and C&P exams.  At the MEB examination the CI reported being able to walk a mile or bicycle for up to an hour and at the C&P exam the CI had a normal gait and reported foot pain present less than half the time at the C&P exam.  Therefore, the Board concluded the disability due to each foot was best described as `slight’ and not `moderate’ and each foot condition met the 0% rating.  The Board finally reviewed to see if a higher evaluation could be achieved for either or both feet with any other applicable coding approach.  Members, noted that by similar reasoning as elaborated above for the 5310 criteria, the CI’s foot condition did not rise to the level of being characterized as `moderate’ coded as 5284 (other foot injury), and there was no evidence of tarsal or metatarsal malunion or non-union, or claw foot deformity to support a higher rating.  The Board determined that the evidence in record supports a 10% rating for the bilateral pes planus and no higher, including consideration of functional loss.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), and §4.40, the Board recommends a disability rating of 10% for the bilateral foot condition, coded 5276.

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 bilateral knee and bilateral foot conditions was operant in this case and the conditions were adjudicated independently of that policy by this Board.  In the matter of the low back condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the bilateral knee condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the bilateral foot condition, the Board unanimously recommends a disability rating as follows: an unfitting left foot condition and an unfitting right foot condition rated 10%, coded 5276 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	
Mechanical Low Back Pain Condition	5237	10%	
Bilateral Knee Pain Condition	5099-5003	0%	
Bilateral Foot Pain Condition…	5276	10%	
COMBINED (w/ BLF)	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140618, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

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, AR20160005459 (PD201402949)

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