RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-04063
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20090219

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-5 (Signals Collector/Analyst) medically separated for right foot pain and narcolepsy.  These conditions could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty or satisfy physical fitness standards.  She was issued a permanent P3, L3 profile and referred for a Medical Evaluation Board (MEB).  The “tarsal tunnel syndrome,” “narcolepsy” and “hypersomnia,” were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also identified and forwarded five other medically acceptable conditions (benign goiter, reactive airway disease, allergic rhinitis, folliculitis and resolved cervical strain) for PEB adjudication.  The Informal PEB adjudicated “right chronic foot pain diagnosed as tarsal tunnel syndrome” and “hypersomnia diagnosed as narcolepsy” as unfitting, rated 10% and 10%, 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:  “The applicant requests consideration of all conditions.  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 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 20081110	VA* - based on Service Treatment Records (STR) 	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Chronic Foot Pain … Tarsal Tunnel Syndrome	5299-5284	10%	Tarsal Tunnel Syndrome, Right Foot	8625	0%	STR	
Hypersomnia … Narcolepsy	8108	10%	Narcolepsy and Hypersomnia	8108	NSC		
Reactive Airway Disease	Not Unfitting 	Reactive Airway Disease	6699-6602	NSC		
Folliculitis	Not Unfitting 	Folliculitis	7899-7806	0%		
Resolved Cervical Strain	Not Unfitting 	Cervical Strain	5237	NSC		
Benign Goiter	Not Unfitting 	No VA Placement	
Allergic Rhinitis	Not Unfitting 		
Other x 0 (Not In Scope)	Other x 5	
RATING:  20%	RATING:  10%	
*Derived from VA Rating Decision (VARD) dated 20091110 (most proximate to date of separation (DOS)).  

ANALYSIS SUMMARY:  

Right Foot Condition.  The CI presented in January 2006 with reports of right foot pain for 30 days.  At that time the CI reported that she had a surgery on the right foot in June 2005.  She was diagnosed with a right second toe hammer toe, plantar fasciitis, and dermatitis.  A podiatric evaluation dated 13 March 2006 noted a soft mass and misalignment of the second toe.  A diagnosis of acquired deformity of the toe; hammer toe with possible fibroma was rendered.  The soft mas (cyst) continued to increase in size with aggravation by shoe gear and ambulation.  In June 2007 that CI underwent surgical incision and drainage of the cyst.  The pain in the second to resolved; however the CI continued to report pain at the plantar aspect of the right foot.  A podiatric note dated 3 January 2008 documented physical findings consistent with tarsal tunnel syndrome and capsulitis of the second right metatarsophalangeal joint.   The narrative summary (NARSUM) noted that the right foot pain did not respond to physical therapy and pain management.  The physical examination demonstrated 4/5 dorsiflexion and bilateral tenderness to palpation at the planter surface and tarsal tunnel; right greater than left.  

The CI failed to appear at her scheduled VA Compensation and Pension examination.  The goniometric range-of-motion (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)	Ortho ~5 Mo. Pre-Sep
(20080910) 	Podiatry ~20 Mo. Post-Sep
(20101026) 	
Dorsiflexion (20 Normal)	20	10	
Plantar Flexion (45)	45 (50)	25	
Comment	Painful motion, pain with use		
§4.71a Rating	10%	10%	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the right foot pain condition at 10% analogous to moderate foot injury IAW VASRD §4.10, §4.40, §4.45 and §4.59; coded 5299-5284 (foot injury, other).  VA rated the condition 0% based on Service treatment records; coded 8625 (neuritis of the posterior tibial nerve).  The Board considered whether the evidence supported a higher than 10% rating.  There was no evidence of moderately severe foot injury or severe incomplete paralysis of the posterior tibial nerve for a higher rating.  Considering the totality of the evidence and mindful of VASRD §4.3 (reasonable doubt), members agreed that a disability rating of 10% for the chronic right foot pain condition was appropriately recommended in this case.

Hypersomnia with Narcolepsy.  The CI presented in May of 2003 with reports of a year history of daytime fatigue and sleepiness.  She had a sleep study (multiple sleep latency test) performed which was “borderline” for a diagnosis of narcolepsy.  Treatment records were silent for narcolepsy until May 2008 when the CI presented with snoring and excessive daytime sleepiness.  At that time she was started on medication (Modafinil).  At a mental health visit dated 4 August 2008 the CI reported that she was able to “fight off” her fatigue since beginning the narcolepsy medication.  The physical and psychiatric examinations were normal.  A diagnosis of sleep disorder organic hypersomnia was rendered.  At the NARSUM examination the CI reported daily episodes of sleepiness that were helped, but not prevented by medication.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the unfitting narcolepsy condition at 10% for diagnosis confirmed by sleep study without witnessed or unwitnessed episodes day or night time attacks of irresistible, refreshing sleep.  VA did not Service connect this condition.  The Board considered whether the evidence supported a higher than 10% rating.  Narcolepsy IAW VASRD instructions is rated as epilepsy, petit mal.  There were not episodes of irresistible sleep for a higher rating.  Considering the totality of the evidence and mindful of VASRD §4.3 (reasonable doubt), members that a disability rating of 10% for the narcolepsy condition was appropriately recommended in this case.

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that benign goiter, reactive airway disease, allergic rhinitis, folliculitis and resolved cervical strain 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 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 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 any of the contended 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 matter of the right foot pain condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the narcolepsy condition and IAW VASRD §4.124a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended benign goiter, reactive airway disease, allergic rhinitis, folliculitis and resolved cervical strain 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, 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 w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MEMORANDUM FOR Commander, US Army Physical Disability Agency
(AHRC-00), 2900 Crystal Drive, Suite 300, Arlington, VA 22202-3557

SUBJECT: Department of Defense Physical Disability Board of Review Recommendation
for XXXXXXXXXXXXXXXXXXXXXXX AR20160004455 (PD201404063)

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