RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03108
BRANCH OF SERVICE:  army	SEPARATION DATE:  20080502

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3, Helicopter Repair, medically separated for “left tarsal tunnel syndrome; left foot osteophyte” with a disability rating of 20%.

CI CONTENTION:  The CI contends the left tarsal tunnel condition should be rated higher since it affected his mobility and career.  The CI’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 – 20080317	VARD – 20090407	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Tarsal Tunnel Syndrome; Left Foot Osteophyte Pain	8799-8725	20%	Status Post Left Foot Tarsal Surgery with Scars & Osteoarthritis	5284	10%	20090226	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  60%	

ANALYSIS SUMMARY:

Left Foot Condition.  According to the service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI suffered an atraumatic onset of left foot pain in 2005.  He was diagnosed with plantar fasciitis and underwent a surgical fascial release in May 2006.  He subsequently developed worsening pain and neurologic symptoms diagnosed as tarsal tunnel syndrome (TTS), which was corroborated by imaging (MRI) and confirmed by electrodiagnostic (EMG) testing.  He underwent a surgical tarsal tunnel release in January 2007 (15 months pre-separation).  Subsequent STR entries documented no improvement in symptoms (recovery was hampered by obesity), and a repeat EMG confirmed persistent TTS.  
There were variable STR entries regarding a gait disturbance.  There were several entries indicating normal or nearly so range of motion (ROM) of the foot or ankle, and none indicating significantly limited ROM.  Conservative treatment did not result in improvement sufficient to allow unrestricted duty and the CI was referred for an MEB, which in turn forwarded “left (TTS)” and “left foot osteophyte formation” to the Physical Evaluation Board (PEB).  

At the NARSUM examination on 2 November 2007, 6 months before separation, the CI complained that his pain was worse since the surgery, and the examiner documented a 15-20 minute standing tolerance and 20 minute walking tolerance.  The commander’s performance statement documented limitations with rigorous duty and general soldiering requirements.  The NARSUM physical examination recorded an “arthralgic gait due to brace on left foot,” significant tenderness, sensory and extensor motor loss of the lateral toes, with mildly (4/5) reduced strength for ankle dorsiflexion (DF) and plantar flexion (PF).  The ankle ROM measurements were DF to minus 5 degrees (normal 20) and PF to 35 degrees (normal 45).

A General VA Compensation and Pension (C&P) examination on 29 July 2008, 3 months after separation, documented “walks with a limp using a brace and is morbidly obese” and recorded 5/5 strength but decreased sensation of the left foot.  There was no ROM evidence.  A VA podiatry C&P examination of 11 September 2008, 5 months after separation, documented “pain all day, every day” with a 1/2 mile walking tolerance, inability to run, and difficulty with stairs.  The physical examination recorded “exquisite” tenderness, 5/5 strength (no comment for sensory), and ROM measurements of DF 25 degrees and PF 10 degrees (no degradation with repetition).  A second general C&P examination on 26 February 2009, 10 months after separation, documented pain rated 10/10 limiting standing (15-30 minute tolerance) and walking.  The physical examination recorded a normal gait with use of foot brace, with the absence of tenderness, weakness, edema, or atrophy; and, specifically denied the presence of all VASRD ratable foot deformities.  The ROM measurements were DF 20 degrees and PF 25 degrees, specifying no painful motion.  

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB conferred a 20% rating under the nerve code 8799-8725 (analogous to neuralgia of the posterior tibial nerve (accurate for TTS), citing “severe” impairment (the VASRD §4.124a criterion for 20% under 8725).  The VA conferred a 10% rating under code 5284 (foot injuries, other), citing evidence from the second general C&P examination.  The 10% criterion under 5284 is “moderate” disability, and it offers a 20% rating for “moderately severe” and 30% for “severe” disability.  Members agreed that the PEB’s choice of rating under a nerve code was appropriate for the clinical features and disability in this case, and no higher rating was achievable via that coding option.  The maximum rating for ROM limitation is also 20% (code 5271) and there is no other foot or joint code under VASRD §4.71a which is applicable or favorable in this case, except for the VA’s 5284.  Although the evidence indicated significant functional limitations at separation, members agreed that they could not be reasonably characterized as severe in support of a 30% rating under 5284.  Since the ROM limitation and functional impairment were due to pain, members agreed that separate ratings under nerve and joint codes would violate VASRD §4.14 (avoidance of pyramiding).  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 of the left foot condition. 

BOARD FINDINGS:  In the matter of the left foot condition and IAW VASRD §4.124a, the Board unanimously recommends no change in the PEB adjudication.  There were no other conditions within the Board’s scope of review for consideration.  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 20140521, with attachments
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 XXXXXXXXXXXXXXXXXXXXXXX AR20160011109 (PD201403108)

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