RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03963
BRANCH OF SERVICE:  Army	SEPARATION DATE:   20061205

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E2, Basic Trainee, medically separated for “stress fracture, right calcaneus” and “chronic back pain,” rated 10% and 10%, respectively, with a combined disability rating of 20%.

CI CONTENTION:  “Please consider all conditions.”  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 - 20061115	VARD - 20070514	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Stress Fracture, Right Calcaneus.	5299-5279	10%	Status Post Right Ankle Stress Fracture	5299-5271	NSC	20070424	
Chronic Back Pain, due to Lumbar Degenerative Disc Disease	5299-5242	10%	Lumbar Strain with Mild Degenerative Disc Disease and
Left Lumbar Radiculopathy	5243-5237	40%	20070424	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Stress Fracture, Right Calcaneus.  The service treatment record and the Medical Evaluation Board (MEB) narrative summary (NARSUM) dated 22 August 2006 indicated the CI began having pain in his right heel during basic training with a history of antecedent ankle and knee pain.  On 25 April 2006 the CI had foot pain felt to be soft tissue in origin, which was treated with Indocin (indomethacin, a nonsteroidal anti-inflammatory drug [NSAID]) and a profile.  X-rays of the right ankle on 6 May 2006 showed soft tissue swelling for which crutches were prescribed.  There was tenderness on palpation over the calcaneus (heel bone).  A bone scan performed on 30 May 2006 for persistent ankle and heel pain showed a stress fracture of the right calcaneus.  The CI reported 3/10 right heel pain with a positive heel squeeze.  Despite transfer to the Physical Training and Rehabilitation Program in mid-June 2006, there was no improvement in his symptoms, which prevented him from running, walking, marching, or other physical training.  Partial healing of the heel was noted on 10 July 2006.  A removable heel pad was dispensed on 28 July 2006, but the CI reported increased pain of 7/10 (10 being the worst pain) with weight bearing.  An orthopedist noted no tenderness on right calcaneus on 1 August 2006 and indicated the lower extremity presented no further evidence of residual stress reaction of soft tissue or bone on 15 August 2006.  However, the NARSUM examiner noted the right calcaneus was tender with minimal swelling on 22 August 2006.  

At the MEB examination dated 7 August 2006, the CI reported on DD Form 2807-1 he had a stress fracture of the calcaneus “but still pain.”  The MEB physical examiner noted “tender os calcis” (heel bone) and “no swelling noted, full range-of-motion [ROM].”   The commander’s statement dated 9 August 2006 indicated the CI’s injury and current medical profile prevented him from successfully completing basic combat training or advanced individual training.  A permanent L3 profile was issued on 22 August 2006 for a closed stress fracture of the right calcaneus-non healing and degenerative disc disease of the lumbar spine (see below) with limitations of all physical fitness testing and all functional military activities.  

At the VA Compensation and Pension (C&P) examination dated 24 April 2007, performed approximately 5 months after separation, the CI reported “there was a fracture to the right ankle in the service.”  He had no pain regarding the ankle since then.  Examination of the right ankle revealed a full ROM with dorsiflexion to 25 degrees, plantar flexion to 50 degrees, inversion 40 degrees and eversion 20 degrees.  The motions caused a mild sensation of discomfort; however, there was no pain or limitation of motion with repetition.

The ROM evaluations in evidence which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below.

Right Ankle ROM
(Degrees)	MEB ~4 Mo. Pre-Sep
(20060822) p.35	VA C&P ~5 Mo. Pre-Sep
(20070424) p.119	
Dorsiflexion (20 Normal)	Full ROM	25	
Plantar Flexion (45)		50	
Comment	Tender calcaneus with minimal swelling	Mild sensation of discomfort with motion; no limitation of motion with repetition	
§4.71a Rating	PEB 10%	VA NSC	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating using code 5299-5279 (metatarsalgia) for a stress fracture, right calcaneus.  The VA used code 5299-5271 (ankle, limited motion) for status post right ankle stress fracture, but found it not service connected and not subject to compensation. 

The Board sought a route to a higher rating and noted code 5284 (Foot injuries) is more appropriate; however, a moderate foot injury affords only a 10% rating, which does not offer any additional benefit to the CI.  There was insufficient evidence to support a moderately severe injury with a 20% rating.  In the absence of evidence of a severe unilateral flatfoot or claw foot or moderately severe tarsal or metatarsal bones malunion or nonunion, there was no route to a higher rating.  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 stress fracture of the right calcaneus condition.

Chronic Back Pain, due to Lumbar Degenerative Disc Disease.  A note dated 10 April 2006 indicated the CI was seen for a backache.  X-rays of the lumbar spine dated 17 July 2006 showed multilevel degenerative disc disease with some neural foraminal stenosis at L4-5 and L-5-S1.  On 24 July 2006 the CI reported complaining of back pain for a week, which had been present for approximately 2.5 months along with heel pain (see above), but the back pain did not radiate to the hips or legs and bowel and bladder function was normal.  On 28 July 2006 the CI reported constant, sharp pain lower back pain 6/10 without radicular symptoms.  An orthopedic examination on 1 August 2006 revealed no deviations or deformities of the spine, no muscle spasm, and no motor or sensory deficits.  On 3 August 2006 there was tenderness on palpation of the right and left paraspinal regions.  An X-ray series of the lumbar spine showed a right L5/S1 facet defect probably developmental and absence of the lordosis of the lumbar spine.  At an orthopedic examination dated 15 August 2006 the CI’s lower back had an area of significant tenderness at the lumbar region with minimal muscle spasm.  Straight leg raises (to determine nerve root irritation) both standing and sitting were negative. 

At the MEB examination dated 7 August 2006, the CI reported on DD Form 2807-1 beginning signs of arthritis in the back with “always pain.”   The MEB physical examiner noted on DD Form 2808 for the LS spine there was tenderness of the SI (sacroiliac) joints bilaterally and the ROMs were flexion 90 degrees, extension 5 degrees, lateral bending right 18 degrees and left 15 degrees, rotation right 20 degrees and left 18 degrees with the motions limited by pain.  The commander’s statement dated 9 August 2006 indicated the CI’s injury and current medical profile prevented him from successfully completing basic combat training or advanced individual training.  A permanent L3 profile was issued on 22 August 2006 for a closed stress fracture of the right calcaneus-non healing (see above) and degenerative disc disease of the lumbar spine with limitations of all physical fitness testing and all functional military activities.  The NARSUM examiner on 22 August 2006 noted a full ROM of the lumbar spine with tenderness over the L3-S1 spinous processes with no muscle spasm.  The NARSUM ROMs were the same as those of the MEB (see above).  A CT (computerized axial tomography) examination of the spine dated 5 September 2006 showed some very minimal degenerative changes at the discs L4-5 with slight encroachment of the intervertebral foramina and at L5-S1 with very slight compromise of the intervertebral foramina (openings between vertebra where nerves pass).
 
At the VA Compensation and Pension (C&P) examination dated 24 April 2007, performed approximately 5 months after separation, the CI reported low back pain with moderate intensity, which shot to the left leg and the entire left foot and the leg fell asleep at times.  He had no incapacitation and indicated he avoided lifting groceries and boxes or pulling weeds.  On examination he had a mild antalgic gait and used no assistive devices.  The CI did not have any specific deformities or spasm of the spine, which was nontender.  ROM measurements were forward flexion  30 degrees one time only, extension 10 degrees, right and left lateral flexion 30 degrees each, and right and left lateral rotation 30 degrees each.  All motions caused a sensation of pain.  Neurologic examination and strength of the lower extremities were normal.  

The ROM evaluations in evidence which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below.

Thoracolumbar ROM
(Degrees)	MEB ~4 Mo. Pre-Sep
	VA C&P ~5 Mo. Post-Sep
	
Flexion (90 Normal)	90	30	
Extension (30)	5	10	
R Lat Flexion (30)	(20)18	30	
L Lat Flexion (30)	15	30	
R Rotation (30)	20	30	
L Rotation (30)	(20)18	30	
Combined (240)	170	160	
Painful motion	Present 	Present	
Tenderness	Present 	Absent	
*Spasm or guarding	Absent 	Absent	
**Altered Gait 
  due to *	Not Addressed	Absent	
**Altered contour due to *	Not addressed	Absent	
***Incapacitating episodes IVDS	Not Addressed	Not Addressed	
Misc Functional Loss	Not Addressed	Not Addressed	
Comment	Tender L3-S1 spinous processes, no muscle spasm; ROM limited by pain	Spine nontender; no spasm; sensation of pain with motion; neurologic examination normal	
§4.71a Rating	PEB 10%	VA 40% 	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating using code 5299-5242 (Degenerative arthritis of the spine) for chronic back pain based on limitation of motion due to pain and localized tenderness.  The VA assigned a 40% rating using code 5243-5237 (Intervertebral disc syndrome-lumbosacral strain) for lumbar strain with mild degenerative disc disease and left lumbar radiculopathy based on limitation of forward motion.  The Board sought a route to a higher rating prior to separation; however, in the absence of ankylosis, forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees,  muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour, or episodes of incapacitation was unable to do so.  The Board members did note the significant disparity of the ROM for flexion at VA examination approximately 4 months after separation.  While the CI’s forward flexion was normal at 90 degrees at MEB examination approximately 4 months pre-separation, flexion was only 30 degrees, performed but one time only, at the VA examination 5 months after separation, but the ROMs of all other motions were normal and there was no muscle spasm.  It would be speculation to draw a conclusion whether the 30 degrees was as high as 32 degrees or was as low as 28 degrees since the VASRD §4.71a General Rating Formula for Diseases and Injuries of the Spine Note (4): states: “Round each range of motion measurement to the nearest five degrees.”  Examinations and imaging prior to separation do not provide an explanation for the disparity nor did the record provide evidence to indicate a further injury, an unusual twist, or lifting of a heavy object, which would have induced the diminished flexion ROM either prior to separation or after separation.  In the absence of credible evidence to explain a single finding a flexion of 30 degrees, the Board could not recommend a 40% rating as did the VA, which also included the left lumbar radiculopathy.  

The Board then considered whether an additional Service rating could be recommended under a peripheral nerve code.  Although the pain component of the neuropathy is appropriately subsumed in the spine rating IAW VASRD §4.71, which states that “rating is performed with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease,” there was no sensory component with any significant functional implications and no motor weakness was in evidence.  Therefore, a radiculopathy could not be recommended for additional disability rating.  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 chronic back pain condition.

BOARD FINDINGS:  In the matter of the stress fracture of the calcaneus condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the chronic back pain condition and IAW VASRD §4.71a, 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 20140911, with attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAMR-RB

28 JUL 2016

MEMORANDUM FOR Commander, US Army Physical Disability Agency
(AH RC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA 22202-3557

SUBJECT: Department of Defense Physical Disability Board of Review Recommendation
for XXXXXXXXXXXXXXXXXXXX, AR20160009428 (PD201403963)

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