RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03903
BRANCH OF SERVICE:  Army  	SEPARATION DATE:  20090520  

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-2 (Fire Support Specialist) medically separated for bilateral patellofemoral pain syndrome.  The bilateral knee condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS).  He was issued a permanent L3 profile which allowed for an alternate aerobic event to satisfy physical fitness standards and was referred for a Medical Evaluation Board (MEB). “Bilateral patellofemoral pain syndrome” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also identified one other medically unacceptable condition (bilateral pes planus with chronic foot and ankle pain) and nine conditions that met retention standards (left flexor hallucis longus tenosynovitis, chronic partial tearing of the tibialis posterior, bilateral hallux abductor valgus, mild, bilateral hammer digit syndrome, tailor’s bunions, tinnitus AD, hyperlipidemia, dysphagia, and heartburn) for PEB adjudication.  The Informal PEB adjudicated “bilateral patellofemoral pain syndrome” as unfitting, rated 10% right and 10% left, citing application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The remaining conditions were determined to be not unfitting.  The CI made no appeals and was medically separated.  

CI CONTENTION:  He was given a higher rating for his conditions by the VA.  His complete submission is at Exhibit A.

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44, Enclosure 3, paragraph 5.e. (2).  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/Naval 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 VASRD on 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 20090311	VA* - (~1 Mos. Post-Separation) 	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Patellofemoral Pain Syndrome	5099-5003	10%	Right Knee Retropatellar Pain Syndrome w/Mild Tendonosis	5299-5260	10%	20090619	
		10%	Left Knee Retropatellar Pain Syndrome w/Mild Tendonosis	5299-5260	10%	20090619	
Bilateral Pes Planus with Chronic Foot and Ankle Pain	Not Unfitting	Left Foot Pes Planus with Early Bunion Formations and Degenerative Changes	5284	10%	20090619	
		Right Foot Pes Planus with Early Bunion Formations and Degenerative Changes	5284	10%	20090619 	
		Right Ankle Bursitis	5271	10%	20090619	
Partial Tearing of the Tibialis Posterior	Not Unfitting	Left Ankle Tendonosynovitis and Chronic Partial Tear of Tibialis Posterior	5271	10%	20090619	
Left Flexor Hallucis Longus Tenosynovitis	Not Unfitting					
Tailor’s Bunions	Not Unfitting	Included in left and right foot conditions	
Bilateral Hallux Abductor Valgus, Mild	Not Unfitting	Included in left and right foot conditions 	
Bilateral Hammer Digit Syndrome	Not Unfitting	Included in left and right foot conditions	
Tinnitus AD	Not Unfitting	No VA Placement	
Hyperlipidemia	Not Unfitting	No VA Placement	
Dysphagia	Not Unfitting 	No VA Placement	
Heartburn	Not Unfitting	No VA Placement	
Other MEB/PEB Conditions x 0 (Not In Scope)	Other x 2 	
COMBINED RATING:  20%	COMBINED RATING:  50%	
*Derived from VA Rating Decision (VARD) dated 20091223 (most proximate to date of separation (DOS)).  

ANALYSIS SUMMARY.  The Board notes that the PEB adjudicated bilateral patellofemoral pain but provided individual 10% ratings for each knee, coded 5099-5003, for a combined 20% rating, with the bilateral factor applied.  Therefore, the Board deliberated separate rating recommendations below for the unfitting right knee and the unfitting left knee at separation.  

Bilateral Patellofemoral Pain Syndrome.  The narrative summary (NARSUM) notes the CI reported bilateral knee pain that developed in June 2008 while running.  Notes in the service treatment record (STR) indicated that a bone scan on 5 March 2008 performed for foot pain (discussed further under the contended condition section below) noted increased uptake in both knees consistent with stress changes.  A physical therapy (PT) evaluation on 31 July 2008 noted tenderness to palpation (TTP) of both patellae, with full range-of-motion (ROM) and normal strength with pain, no instability or evidence of meniscal (semilunar cartilage) injury.  A primary care visit 17 October 2008 noted that the CI reported pain in the knees and ankles which the examiner found vague, and exam of the knees, ankles, and feet was unremarkable.  Screening laboratory tests for systemic joint disorders were ordered (ESR, rheumatoid factor) and magnetic resonance imaging (MRI) of the bilateral knees and ankles was ordered, with consideration of an MEB if no remedial cause was found for the pain.  The bilateral knee MRI noted possible mild tendinitis of the right knee and possible small collection of fluid in the left knee near the medial meniscus, without evidence of a meniscal tear.  The radiologist’s impression was “relatively unremarkable” MRI of both knees.

At the MEB exam 4 February 2009, 3 months before separation, the CI reported daily bilateral knee pain under the kneecaps that worsened throughout the day, left greater than right.  He reported he was given a cane and bilateral knee braces.  Medications included pain medication, anti-inflammatory medication and acetaminophen daily.  The MEB physical exam noted the CI walked using a cane with a left limp.  There was tenderness of both knees about the patella, with crepitus, without evidence of instability or meniscal injury.  The examiner noted the CI was unable to cooperate to provide reliable ROM evaluation due to pain and active resistance to testing was noted.  Right knee ROM was extension-flexion of 0 to 120 degrees (normal 0 to 140) and left knee ROM was 0 to 125 degrees.  There was no additional loss of ROM of either knee with repetition.

At the VA Compensation and Pension (C&P) exam 19 June 2009, 1 month after separation, the CI reported knee pain aggravated by activity.  The exam noted the CI used a cane and ambulated with an antalgic gait favoring the left.  There was tenderness globally about the knee with crepitus and no instability.  Right and left knee ROM was 0 to 120 degrees, with painful motion and no additional loss of ROM with repetition.  There was normal strength, sensation, and reflexes of the lower extremities, with normal pulses.  Additional screening tests associated with systemic connective tissue disorders were negative.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the right and left knees 10% each, coded 5099-5003 (analogous to degenerative arthritis) and the VA also rated each knee 10%, coded 5299-5260 (analogous to limited leg flexion) for bilateral retropatellar pain syndrome.  The Board agreed the evidence supports a 10% rating for each knee, coded either 5099-5003 or 5299-5260, and reviewed to see if there was support for a higher evaluation of either or both knees with any applicable code.  No higher than a combined 20% rating is available coded according to 5003 rating criteria and there was no evidence of limited leg flexion or extension of either leg sufficient to meet the ROM criteria for a 20% rating.  There was no evidence of instability; semilunar cartilage injury with frequent episodes of “locking”, pain , and joint effusions; or, ankylosis of either the right or left knee to support a higher rating.  The Board thus determined that the right and left knee conditions each met a 10% rating and no higher.  After due deliberation, and in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend changes in the PEB adjudication of the right and left knee conditions.  

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that the bilateral pes planus (PP) with chronic foot and ankle pain, left flexor hallucis longus (FHL) tenosynovitis, chronic partial tearing of the tibialis posterior, bilateral mild hallux valgus (great toe bunion), bilateral hammer digit (hammer toe) syndrome, tailor’s bunions (fifth toe bunion), tinnitus AD [right ear], hyperlipidemia, dysphagia, and heartburn conditions were 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 Board first noted that multiple not unfitting conditions - left FHL tenosynovitis, left chronic partial tearing of the tibialis posterior, bilateral mild hallux valgus, bilateral hammer toes, tailor’s bunions - were conditions of the foot and ankle which may have contributed to foot and ankle pain and therefore considered them together with the bilateral PP condition.

Bilateral PP Condition.  The military enlistment physical 17 April 2007 noted bilateral asymptomatic PP.  The NARSUM noted the CI had a history of ankle sprains in his youth, but no problems with his feet at the time of service entry.  The CI first noted pain during basic training, but denied specific injuries.  Notes in the STR indicated the CI was evaluated for a 2-week history of left foot pain aggravated by activity on 3 March 2008.  A bone scan on 5 March 2008 noted increased uptake in the left second metatarsal (MT) consistent with a stress fracture, with lesser uptake in the right second MT possibly consistent with stress injury.  There was also “mild increased uptake in the ankles consistent with stress change” noted.  A follow-up visit 10 March 2008 indicated the left foot pain had resolved.  The CI reported persistent ankle pain and bilateral ankle X-rays 23 June 2008 were normal.  A PT evaluation 31 July 2008 noted an antalgic gait with abnormal push-off of both feet and the CI was unable to heel or toe raise.  There was full ROM noted with normal strength.  As noted in the discussion of the knees, a PC evaluation on 17 October 2008 noted vague pain complaints of the ankles and feet, with normal exam.  Left ankle MRI on 22 October 2008 noted FHL tenosynovitis, chronic partial tear of the tibialis posterior and partial tearing of the flexor digitorum longus, and old injuries of multiple ankle ligaments were noted.  Right ankle MRI was reported as “unremarkable.”  The CI was referred to podiatry for evaluation and treatment of “chronic ankle pathology” resulting in an abnormal gait.  The 4 November 2008 MEB podiatry evaluation noted bilateral ankle pain, right greater than left and PP (flatfoot deformity) of both feet.  The CI reported bilateral ankle/foot pain since basic training without specific trauma and requested an MEB.  The exam noted the feet were neurovascularly intact, without swelling or bruising.  There was TTP of multiple ligaments and tenderness of both ankles with ambulation, and sensation was intact.  There was pain along the course of the right tibialis posterior tendon (provides support to the arch of the foot).  The podiatrist noted hallux valgus (HV), decreased arches with pronated feet, and hammer toe deformity of the second through fifth toes bilaterally, with 3+/5 strength noted with right ankle motions and 3+-4/5 strength on the left.  The podiatrist’s assessment included bilateral PP, FHL tenosynovitis, chronic partial tearing of the tibialis posterior, bilateral mild HV, bilateral hammertoes, and tailor’s bunions.  The podiatrist noted the CI had chronic bilateral ankle pain associated with multiple podiatric conditions which prevented him from wearing military footwear and performing the duties of his MOS.  The CI was given ankle braces and advised on modifications to his shoes and boots and an MEB was recommended.  

The commander’s statement did not note specific medical conditions, but noted that the CI was unable to perform basic soldier skills, such as 3-5 second rushes and ruck marches.  A temporary profile dated 19 June 2008 listed ankle pain and stress fractures of the feet, and one dated 4 November 2008 noted chronic ankle sprain and flatfoot deformities bilaterally.  The permanent profile dated 5 February 2009 listed chronic bilateral ankle/foot and knee pain.  The NARSUM noted the CI was referred for pain related to PP deformity and that his treatment included ankle braces, orthotics and PT.  The MEB examiner listed the bilateral PP diagnosis as not meeting retention standards.  

The DD Form 2808, Report of Medical Examination, dated 8 November 2008, noted laxity and tenderness of the bilateral ankles and indicated chronic foot and ankle pain secondary to ligament injuries and PP.

At the MEB exam, 4 February 2009, 3 months before separation, the CI reported bilateral ankle and foot pain, aggravated by weight-bearing activity and his boots.  The MEB exam largely cited the podiatry evaluation summarized above, but also noted there were no “unusual calluses.”    The MEB examiner noted the exam was limited by the CI’s pain and ROM evaluation was actively resisted and therefore the values were considered unreliable.  Right and left ankle ROM was dorsiflexion (DF) of 10 degrees (normal 20) and plantar flexion of 30 degrees (normal 45). The examiner noted better ankle DF and PF with walking than during ROM testing.  Strength was limited by pain with normal muscle tone and bulk and sensation was intact.  The CI walked with a cane and had a limp favoring the left.  The CI’s functional status noted he was unable to stand or walk for prolonged periods, bend at the ankles without pain, run, do push-ups or sit-ups, or any impact activities.  The NARSUM noted that the PP conditions existed prior to service (EPTS), but were service aggravated (SA) and that the left foot FHL tenosynovitis and partial tear of the tibialis posterior tendon were due to the PP condition, and neither condition individually fell below retention standards.

At the VA C&P exam, 19 June 2009, 1 month after separation, the CI reported constant bilateral ankle and foot pain, aggravated by weight bearing activities and he used ankle braces.  He reported he was told that he had “flat feet” and bunions.  The exam noted a limp favoring the left and the CI was using a cane.  Ankle ROM was right DF 15 degrees and plantar flexion 30 degrees and left DF 12 degrees and PF 25 degrees, all motion with pain.  There was tenderness noted, with normal foot alignment and flatfoot without pronation and weight-bearing line over the great toes bilaterally.  Bilateral foot pain at rest and with manipulation was noted.

The Board first considered if a preponderance of the evidence supports that the bilateral PP condition (inclusive of all the foot and ankle conditions noted above) was unfitting at the time of separation.  The CI reported pain of both ankles and the bilateral PP condition was temporarily and permanently profiled.  The commander’s statement and NARSUM noted physical limitations impaired the CI’s duty performance which may have been contributed to by the bilateral PP conditions.  Physical examination of both feet and ankles were similar, with TTP, ankle and foot pain with ambulation, and PP bilaterally.  The Board agreed that the preponderance of the evidence with regard to the functional impairment of both the right and left PP conditions favors their recommendation as separately unfitting conditions, eligible for individual disability rating.

The Board next deliberated whether any of the other podiatric conditions of the foot or ankle could be recommended as separately unfitting when separated from the PP condition.  Three of the conditions - bilateral mild HV, tailor’s bunions, and bilateral hammer toes - were foot deformities that were neither reported as painful nor noted to be tender on exam and the NARSUM noted that none of these conditions fell below retention standards.  Therefore, the Board concluded there was not a preponderance of evidence to support recommending any of these conditions as separately unfitting.  The Board next considered the fitness implications of the FHL tenosynovitis and chronic partial tearing of the tibialis posterior conditions of the left foot.  Despite the abnormalities of the left ankle and foot noted on MRI, the CI reported bilateral symptoms and at the podiatry evaluation, he reported right greater than left ankle pain and the NARSUM noted that that the podiatrist determined that neither of these left foot conditions individually fell below retention standards.  Therefore, the Board concluded there was not a preponderance of evidence to support recommending either of these conditions as separately unfitting.  The Board thus recommends a single unfitting right foot and a single unfitting left foot condition for additional disability rating.

The Board next directed attention to its rating recommendations for the right and left PP conditions based on the above evidence.  The PEB adjudicated the bilateral PP condition as not unfitting.  The VA rated the right and left PP conditions 10% each, coded 5284 (other foot injury), noting PP and HV, with pain on manipulation of the feet.  The VA noted the PP conditions were EPTS, but were both SA and noted 0% EPTS deductions at the time of service entry.  The VA also rated the right and left ankle conditions 10% each, coded 5271 (limited ankle motion).  The Board agreed that the evidence supports a 10% rating for the PP conditions coded as 5276 (acquired flatfoot) for “moderate; weight-bearing line over or medial to great toe;…pain on manipulation and use of the feet, bilateral or unilateral.”  The Board deliberated whether the evidence provides support to rate each foot separately coded 5284, rather than utilize the VASRD code 5276.  However, the Member consensus was that the evidence supports the CI developed foot and ankle pain in basic training, without any specific injury.  The evaluation of the ankle/foot pain noted imaging and exam findings consistent with symptoms related to PP and PP was the condition that caused the CI to fall below retention standards.  Therefore, the Board determined that 5276 was the most appropriate code to utilize to rate the PP conditions.  The evidence supports a 10% rating for bilateral or unilateral PP and no higher.  The Board considered if additional rating should be recommended for limited ankle motion, but Member consensus was that the disability due to the multiple podiatric conditions was due to pain and two ratings could not be recommended IAW VASRD §4.14 and any contribution to disability from these conditions is subsumed in the Board’s recommended rating for the PP IAW VASRD §4.71a.  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 bilateral PP condition, coded 5276.  

Tinnitus Condition.  The NARSUM noted the CI reported tinnitus (ringing) of the right ear that occurred one to two times weekly when outdoors, with no problem with hearing.

Hyperlipidemia Condition.  The NARSUM noted that the elevated lipids were noted on recent laboratory testing and diet modification was discussed and he was to review further with his PC provider.

Dysphagia Condition.  The NARSUM noted that the CI reported an occasional feeling of bread sticking in his throat since age 16, but he had not had to seek medical attention for it.

Heartburn Condition.  The NARSUM noted the CI reported heartburn for which he tried over- the-counter antacid, but had not tried any other medications or sought medical care.

The tinnitus, hyperlipidemia, dysphagia, and heartburn conditions were not profiled or implicated in the commander’s statement and were not judged to fail retention standards.  All were reviewed and considered by the Board.   There was no performance-based evidence from the record that any of these conditions significantly interfered with satisfactory duty performance.  After due deliberation, and 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 tinnitus, hyperlipidemia, dysphagia, and heartburn conditions and so no additional disability ratings are recommended.

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.  The Board did not surmise from the record or PEB ruling in this case that any prerogatives outside the VASRD were exercised.  In the matters of the right and left knee conditions and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matters of the contended right and left PP conditions, the Board unanimously agrees that they were unfitting and unanimously recommends a disability rating of 10% for bilateral PP, coded 5276 IAW VASRD §4.71a.  In the matter of the left FHL tenosynovitis, chronic partial tearing of the tibialis posterior, bilateral mild HV, bilateral hammer digit syndrome, tailor’s bunions, tinnitus AD, hyperlipidemia, dysphagia, and heartburn conditions, the Board unanimously recommends no change from the PEB determinations as not unfitting.  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; and, that the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective as of the date of his prior medical separation:  

CONDITION	VASRD CODE	RATING	
Right Patellofemoral Pain Syndrome Condition	5099-5003	10%	
Left Patellofemoral Pain Syndrome Condition	5099-5003	10%	
Bilateral Pes Planus Condition	5276	10%	
COMBINED (w/BLF)	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 201340825, 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 (PD201403903)

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 recharacterize 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
( ) DVA