RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX		CASE:  PD-2014-03163
BRANCH OF SERVICE:  Army		SEPARATION DATE:  20061020

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-2 (Basic Trainee) medically separated for “chronic pain left lower leg and ankle, status post tibia/fibular stress fracture, and 1st metatarsal bone scan changes,” rated at 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 condition 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 IPEB – Dated 20060927	VA* - (~10 Mos. Pre-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Pain Left Lower Leg and Ankle; and 1st Metatarsal Bone Scan 	5099-5003	10%	Stress Fracture, Left Distal Fibula	5299-5262	10%	20070801	
			Intertarsal Neuroma Left Foot	5299-5279	10%	20070801	
Pes Planus	Not Unfitting					
Other MEB/PEB Conditions x 0 (Not In Scope)	Other x 8	
RATING:  10%	RATING:  20%	
*Derived from VA Rating Decision (VARD) dated 20071229

ANALYSIS SUMMARY:

Chronic Pain Left Lower Leg and Ankle and 1st Metatarsal Bone Scan Changes.  The earliest note in the service treatment record (STR) dated 11 March 2006 was an X-ray report of the CI’s left ankle, which was ordered for a 3-week history of worsening lateral ankle pain; and it demonstrated a nondisplaced fracture of the left distal fibula.  By 17 April 2006, follow-up X-rays showed healing of the fracture of the left distal fibula.  X-rays of the left foot on 25 April 2006 revealed normal bones, joints and soft tissues.  However, the CI had persistent left foot pain with tenderness on palpation, but no painful motion in May 2006.  A bone scan performed on 22 May 2006 revealed nonspecific moderate intensity uptake in the head of the left foot without evidence of degenerative changes or a stress fracture of the head of the first metatarsal, but there were [shin] splint changes in the distal tibial shafts bilaterally and nonspecific [changes] in the region of the syndesmosis (a slightly movable fibrous joint where the tibia and fibula are joined together by connective tissue) of the left ankle near the fibula.  In July 2006, while undergoing rehabilitation, the CI was prescribed naproxen (a nonsteroidal anti-inflammatory drug (NSAID)) for pain in the left ankle and leg secondary to the fibular stress fracture.  At an orthopedic evaluation on 11 June 2006, the CI noted the stress fracture of the fibula occurred as a result of external rotation of his left foot during an eight mile road march.  The CI’s knees were normal without deformity or laxity; calf muscle girth was increased by 1cm on the left; bilateral pes planovalgus (pes planus-flatfoot with hind foot eversion) was present more noticeable on the left; there was mild tenderness of the left distal tibia, but no inflammatory process of the left ankle was noted.

The commander’s statement dated 12 July 2006 indicated the CI’s injury prevented him from successfully completing Basic Combat Training or Advanced Individual Training.  The CI reported on DD Form 2807-1, Report of Medical History, dated 13 July 2006, 3 months prior to separation, a left fibula fracture, an intermetarsal neuroma of the left foot, and the use of an ankle support, orthotics and a cast.  On DD Form 2697, Report of Medical Assessment, he indicated he could not run, jump, or do any lower extremity exercises.  The MEB examiner reported on DD Form 2808, Report of Medical Examination, a tender distal fibula laterally at the lateral malleolus (outer portion of the ankle) and no tenderness of the foot.  

The MEB narrative summary (NARSUM) examination, dated 02 August 2006, 7 months prior to separation, indicated the CI reported pain in the left ankle area, which began during week 3 of basic training.  He first sought medical care during week 9 and X-rays revealed a nondisplaced fracture of the distal tibia and he subsequently developed left foot pain.  Treatment was with casting, a temporary profile, and convalescent leave.  By 15 April 2006 the cast was removed and X-rays showed a healing fracture.  Because of increasing left ankle and foot pain, a bone scan was performed on 22 May 2006, which showed increased uptake in the head of the first metatarsal on the left and the left ankle in the area of the syndesmosis.  On 5 July 2006 there was complete healing of the left ankle fracture.  A focal examination of the left ankle noted tenderness to percussion and palpation with a full range-of-motion (ROM) and the left foot was non-tender with a full ROM.  A permanent L3 profile was issued on 18 September 2006 for a stress fracture of the left fibula distally and a neuroma (a growth or tumor of the nerve tissue) of the left foot with limitations of all military functional activities and all physical training and testing except walking at the CI’s own pace and distance.

At the VA Compensation and Pension (C&P) examination dated 01 August 2007, 10 months post-separation, the CI indicated the stress fracture of the left distal fibula was attributed to running and rucking; however, he continued on the leg for about 2 months after he was told that it was a sprain at the ankle.  He reported the fracture did heal, but pain persisted.  He also reported stiffness of the ankle area, swelling one to two times per month, weakness, lack of endurance, and tenderness.  He received Celebrex (Celecoxib, an NSAID) and Tramadol (an Opioid-like medication for pain) from a family doctor and wrapped his ankle with an ace bandage while working.  The intertarsal neuroma of the left foot was an incidental finding, although the CI had swelling at the proximal metatarsal bones prior to the diagnosis.  He reported intermittent proximal and distal dorsal foot pain along the base of the 1st and 2nd toe digits.  Nothing specific was done for the foot condition and he had no podiatry evaluation, foot surgery or injections prior to separation.  The left ankle plantar flexion ROM was 0-60 degrees and dorsiflexion (from the VA Rating of Disability (VARD)) was 0-30 degrees with no additional loss of motion due to pain, fatigue, weakness, or lack of endurance following repetitive motion.  There was tenderness to palpation of the dorsal foot at the area of the 1stst/2nd metatarsal space and bilateral moderate interphalangeal joint callus.  Additionally, there was sensory loss of the left medial dorsal foot.

The Board directed its attention to its rating recommendation based on the above evidence. The PEB assigned a 10% rating using code 5099-5003 (Degenerative arthritis) for chronic pain left lower leg and ankle, status post stress fracture and 1st metatarsal bone scan changes.  The VA assigned a 10% using analogous coding 5299-5262 (Tibia and fibula impairment with slight ankle disability) for stress fracture of the left distal fibula and a 10% rating using code 5299-5279 (Metarsalgia, anterior (Morton’s disease)) for an intertarsal neuroma of the left foot.  The Board sought a route to a higher rating and noted that the PEB combined the residual status post left fibula stress fracture pain and the left foot 1st metatarsal bone scan changes.

Although VASRD §4.71a permits combined ratings of two or more joints under 5003, it allows separate ratings for separately compensable joints.  IAW DoDI 6040.44 if the PEB combined adjudication is not compliant with the 5003 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.  If Board members determine by performance based fitness criteria that the condition is reasonable justified as separately unfitting and is separately ratable; IAW VASRD §4.7 (Higher of two evaluations), separate ratings are recommended.  IAW DoDI 6040.44 the combined rating for the conditions determined to be separately unfitting and ratable may not be lower than the single Service disability rating from the PEB.

Although the disability associated with the left ankle was greater than the head of the 1st metatarsal (the joint is either the 1st metatarsal medial cuneiform and/or 1st metatarsal intermediate cuneiform joint), both were profiled, implicated by the NARSUM, and considered to fail retention standards, albeit the 1st metatarsal changes were given the diagnosis of intertarsal neuroma, which was apparently clinically determined by pain in the area of the 1st and 2nd metatarsal space.  Members agreed that the clinical and fitness performance evidence could be reasonably justify each condition as separately unfitting.  However, since the CI’s functional limitations related to pain on walking, running, jumping, marching and standing, VASRD §4.14 (Avoidance of pyramiding), which states “The evaluation of the same disability under various diagnoses is to be avoided” should be considered to be potentially applicable, but bearing in mind that while the ankle and foot have overlapping anatomical structures, the metatarsal bones are independent of the ankle, but nevertheless do function more often than not with the ankle.  Therefore, retention of the 10% rating using code 5099-5003 is not unreasonable especially since at the time of the NARSUM examination the CI’s left foot was non-tender with a full ROM, which would rate 0%, and would afford no advantage to the CI even if a separate rating were not limited by pyramiding.  The Board then discussed whether the code 5299-5262 (Tibia and fibula impairment with slight ankle disability) can be applied for the ankle condition.  The Board agreed it could be used more appropriately at a 10% rating for a mild ankle disability since the stress fracture was healed at the time of separation; rather than a 20% rating for moderate ankle disability, which may have been applicable prior to treatment and eventual resolution of the fracture.  The Board did note that the VA provided a separate rating for the intertarsal neuroma using code 5299-5279 (Metarsalgia, anterior (Morton’s disease)) at 10% without necessarily invoking a discussion relating to VASRD 4.14.  Furthermore, use of a nerve code 8723 for neuralgia of the anterior tibial nerve (deep peroneal) was discussed, but since there was no motor deficit and only a sensory deficit on the VA examination, a mild neuralgia, if it were to be applied, would warrant a 0% rating at the most, thereby affording no additional benefit to the CI.

On the other hand, the Board discussed and considered the pain of the foot emanating from the area of the 1st metatarsal, especially in a recruit, who must run, march, or ruck, to be separately and independently unfitting, not only from anatomical and functional standpoints, but because of its mention as a separate diagnostic entity by the MEB, profile, commander’s statement, and the VA.  The Board then discussed, deliberated, and determined that the condition was not within the spectrum of the caveat of pyramiding and a separate rating was warranted.  Since the bone scan localized the abnormal area to the head of the 1st metatarsal, code 5299-5279 is appropriate.  The Board members at that point discussed whether the CI’s symptoms were compatible with a 10% rating.  The Board favored a 0% rating rather than a 10% rating because there was an absence of specific treatment and no pain at the NARSUM examination or consultation with either a podiatrist or neurologist and only tenderness to palpation at the VA examination.  The Board agreed although this rating does not benefit the CI, it is in concert with the anatomical and functional degree of disability at the time of separation.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (Reasonable doubt), the Board recommends a disability rating of 10% for the chronic pain left lower leg and ankle, status post stress fracture condition, and a 0% rating for the 1st metatarsal bone scan changes condition.

Other Contended PEB Condition-Pes Planus.  The Board’s main charge is to assess the fairness of the PEB’s determination that pes planus 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 pes planus was not profiled or implicated in the commander’s statement and was not judged to fail retention standards.

At the MEPS examination dated 6 October 2005 prior to enlistment, the CI was noted to have pes planus “NCD” (not considered disqualifying) and mild and asymptomatic were circled.  A note dated 11 June 2006 indicated bilateral pes planovalgus was present and was more noticeable on the left and the diagnosis of a congenital foot deformity, pes planus, was made.  The MEB examiner on 13 July 2006 noted “pes planus seen” and circled mild and symptomatic and recorded “pes planus—orthotics—no pain.”  The NARSUM author on 2 August 2006 considered the pes planus to have been EPTS (existed prior to service) as did the MEB, and the PEB determined it was not separately unfitting, but noted “It predisposes to further stress injuries but by itself is not unfitting.”

The aforementioned was reviewed and considered by the Board.  There was no performance based evidence from the record that the pes planus condition 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 for the pes planus contended condition and so no additional disability rating is recommended.

BOARD FINDINGS:  As discussed above, PEB reliance on the USAPDA pain policy for rating the left lower leg, ankle and 1st metatarsal conditions was operant in this case and the conditions were adjudicated independently of that policy by this Board.  In the matter of the chronic pain left lower leg and ankle condition, the Board unanimously recommends a disability rating of 10%, coded 5299-5262 IAW VASRD §4.71a.  In the matter of the 1st metatarsal bone condition, the Board unanimously recommends a disability rating of 0%, coded 5299-5279 IAW VASRD §4.71a.  In the matter of the contended pes planus condition, the Board unanimously recommends no change from the PEB determination as not unfitting.  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, effective as of the date of his prior medical separation:

CONDITION	VASRD CODE	RATING	
Chronic Pain Left Lower Leg and Ankle, S/P Post Fibular Stress Fracture	5299-5262	10%	
1stt Metatarsal Bone Scan Changes	5299-5279	0%	
RATING	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140630, 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 XXX, Arlington, VA 22202-3557

SUBJECT: Department of Defense Physical Disability Board of Review Recommendation
for XXXXXXXXXXXXXXXXXXXX, AR20160005024 (PD201403163)

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 description
without modification of the combined rating or 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: