RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03566
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20020911

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3, Motor Transport Operator, medically separated for “chronic mechanical low back pain…”rated 10%.

CI CONTENTION:  The CI requests that all conditions be considered.  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 – 20020515	VARD - 20030424	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Mechanical LBP…	5299-5295	10%	Lumbar Strain…	5295-5292	10%	2001122	
Foot Pain… Bilateral…EPTS	5202	---%	B/L Hallux Valgus w/ Pes Planus	5276-5280	NSC		
Adjustment D/O…	Not a Physical Disability	Major Depression with Associated Anxiety & Insomnia	9434	50%	20021206	
Personality D/O…						
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  70%	

ANALYSIS SUMMARY:  

Chronic Mechanical Low Back Pain.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s low back condition began in November 2000 with no history of trauma.  Despite treatment, the low back condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and the CI was referred for MEB.  The MEB forwarded “mechanical low back pain” for PEB adjudication.

At an orthopedic consultation in February 2002 (9 months pre-separation), physical examination showed a normal gait with lumbar range of motion (ROM) that was within normal limits within 18 inches to the floor with difficulty (painful motion).

At the MEB examination (documented on Standard Form 88) dated 3 April 2002 (5 months pre-separation), the physical examination showed a “normal” spine examination.  During the MEB NARSUM examination dated 26 April 2002, the CI denied radicular, bowel or bladder symptoms.  The physical examination showed a normal gait, no spasms and ROMs that were within normal limits.  There was also normal strength, sensation and reflexes.

At the VA Compensation and Pension (C&P) examination dated 22 November 2002 (2 months post-separation), the CI reported back pain exacerbated by standing more than 15-20 minutes.   The physical examination showed normal gait with ROM flexion to 80 degrees, and extension 30, bilateral lateral flexion 30, and bilateral rotation 30.  There was negative testing for nerve tension.  Radiographic evaluation was normal.

The Board directed attention to the rating recommendation based on the above evidence.  The PEB rated the low back condition 10% analogously code 5299-5295 (lumbosacral strain), citing “chronic paravertebral muscle spasms… with characteristic pain on motion,” and no evidence of neurologic abnormality.  The VA rated the low back condition 10% analogously coded 5295-5292 (spine, limitation of motion, lumber, slight) based on the VA C&P examination 2 months after separation, citing “mild loss of range of motion due to pain.”

In accordance with DoDI 6040.44, the Board is required to recommend a rating IAW the VASRD in effect at the time of separation, which was the 2002 VASRD standards for the spine.  The Board agreed that a 10% rating was sufficiently supported by the orthopedic, MEB examinations and VA C&P examination utilizing analogous code 5299-5295 based on “slight” limitation of motion.  There was no muscle spasm on extreme forward bending, loss of lateral spine motion, unilateral, in standing position to support the 20% rating.  Board members also agreed that the ROM values more closely approximated the slight (10%) than the moderate (20%) rating under code 5292 (lumbar spine limitation of motion).  There was no vertebral fracture (5285), complete spine ankylosis (5286), lumbar spine ankylosis (5289), or sacroiliac injury/weakness (5294) for consideration under these respective codes.  There was no neurological findings of abnormal reflexes or strength and no recurring attacks for consideration under intervertebral disc syndrome (5293).  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 low back condition.

Foot Pain due to Bilateral Bunions.  According to STR and the MEB NARSUM, the CI’s bilateral foot pain began during basic training.  There was no indication on the entrance physical of bunions on either foot, or any foot pain.  A podiatry consultation in August 2000 diagnosed hallux valgus (bunions) bilaterally and in 2001 a surgical option was declined.  At orthopedic clinic visits in February and March 2002, the CI reported pain and swelling over the bilateral bunions, pain while wearing boots and with running, and no relief from inserts.  Physical examination showed tenderness without swelling of the bunions bilaterally and no metatarsalgia.  Dorsiflexion of the first great toe was to 20 degrees without pain.  Radiographic imaging documented bilateral bunion deformities considered as “mild” by the examiner.  The examiner found no surgical indication due to the CI having “asymptomatic feet in tennis shoes.”  Despite treatment, the bilateral foot condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and the CI was referred for MEB.  The MEB forwarded “mild bunion deformities” for PEB adjudication.

At the MEB NARSUM examination dated 26 April 2002 2002 (5 months pre-separation), the CI reported bilateral foot pain and swelling with inability to wear military shoes.  The physical examination showed a normal gait, right greater than left hallux valgus deformities with normal ankle reflex, and midfoot and subtalar motion.  There was bunion tenderness without evidence of edema, bursitis, or metatarsalgia.  There was full ROM of the digits and flexible pes planus deformities bilaterally.  The examiner diagnosed the bunion deformities as existing prior to service with no service aggravation.  

At the VA Compensation and Pension (C&P) examination dated 22 November 2002 (2 months post-separation), the CI reported right foot pain.  She also reported swelling and inability to wear heels or boots, with use of flip flops most of the time.  Physical examination showed a normal gait, right ankle dorsiflexion to 10 degrees (normal 20), and plantar flexion to 10 (normal 45).  There was no pain, erythema, or inflammation noted on palpation of the feet.  The examiner diagnosed “hallux valgus deformity… with mild loss of range of motion due to pain.”

The Board directed attention to the rating recommendation based on the above evidence.  The PEB coded the bilateral foot condition 5202 (humerus, other impairment) [likely typo], citing “compelling evidence” that the condition was EPTS with no permanent service aggravation.  The VA did not service-connect the bilateral foot conditions analogously coded 5276-5280 (flatfoot, acquired - hallux valgus) based on the STR, citing the PEB’s determination that the foot condition was EPTS and considered a constitutional developmental abnormality with no evidence that the condition permanently worsened as a result of service.

Although there was documentation of bilateral, asymptomatic, “moderate” pes planus at service entry, the Board agreed there was no documentation of a painful foot condition and no evidence of preexisting bilateral hallux valgus/bunions.  There was a specialist’s opinion that the condition was EPTS without permanent service aggravation, but no accepted medical principles to explain how the bilateral foot condition was not permanently service aggravated was offered.  Given the repetitive micro-trauma from training and boot wear the Board concluded that there was no virtual certainty that the bilateral foot condition was not permanently service aggravated.

In consideration of possible ratings, the Board agreed that VASRD code 5280 (hallux valgus, unilateral) or 5282 (hammer toe) most appropriately delineated the pathology in this case.  In consideration of code 5280, the disability in evidence did not rise to the level of “severe, equivalent to amputation of great toe” therefore a 10% rating is also not justified, and each foot would rate 0% IAW VASRD §4.31 (no percent rating).  In consideration of code 5282, each foot had a single toe deformity and would rate no higher than 0% for each foot.  The Board also considered other analogous coding, but none would be of benefit to the CI.  

After due deliberation, considering all of the evidence, the Board concluded the bilateral foot conditions were permanently service aggravated; however, neither foot condition rated separately or combined, would rate higher than 0%, which is of no rating benefit to the CI.  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 bilateral foot condition.

Contended PEB Conditions:  Adjustment Disorder with Mixed Emotional Features and Personality Disorder NOS with Borderline and Histrionic Features.  Each of the contended conditions is a condition not constituting a physical disability, IAW DoDI 1332.38.  Therefore, the Board has no basis for recommending either as unfitting.  

BOARD FINDINGS:  

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 foot condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended adjustment and personality disorder conditions, the Board unanimously recommends no change from the PEB determinations.  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 20140730, 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

21 NOV 2016

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for 
XXXXXXXXXXXXXXXXXX, AR20160017549 (PD201403566)

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.

Enclosure

CF: 
(  ) DoD PDBR
(  ) DVA