RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-04287
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20070116

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Wheeled Vehicle Mechanic, medically separated for “chronic bilateral foot pain,” with a disability rating of 20%.

CI CONTENTION:  He was not evaluated for back, knee, hand and PTSD conditions.  His 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 based upon a 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 - 20061010	VARD - 20071029	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Bilateral Foot Pain…	5299-5276	20%*	Chronic Bilateral Foot Pain…	5299-5276	0%	STR	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  0%	
*Determined hammertoes and corns existed prior to service, rated 30% and applied a 10% deduction.

ANALYSIS SUMMARY:

Chronic Bilateral Foot Pain.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI first sought care in his second week of basic training (16 August 1999) for bilateral foot pain present for one month.  There was no history of trauma.  Examination at that time showed multiple foot deformities including pes planus (flat feet), multiple bilateral claw toes, bilateral 5th hammertoes, a deformity of each big toe (hallux abductus interphalangeus) and diffuse plantar callus formation beneath the metatarsal heads.  Because the 5th hammertoes were the most bothersome, in 2003 surgical correction of the left 5th toe was performed and in 2004 the same procedure was performed on the right.  Following surgery; however, further treatment of bilateral foot pain did not result in improvement sufficient to allow unrestricted duty.  The MEB forwarded “soft tissue pain on bilateral feet secondary to pes planus (severe), bilateral hammertoes status post surgery on the fifth pinkie toe, and bilateral metatarsalgia secondary to callusing” for PEB adjudication.

A primary care clinic entry in October 1999 indicated that, although the CI had no complaints of foot problems prior to enlistment, the foot condition existed prior to service entry (EPTS).  A podiatrist in December 1999 also indicated that the bilateral toe deformities were EPTS.

At a primary clinic evaluation on 17 May 2006, 8 months prior to separation, the CI complained of numbness in the feet and a 5 year history of pain in the ball and arch of each foot.  Pain was worse with weight-bearing.  Physical examination showed bilateral pes planus, and no swelling, tenderness or painful motion of either foot.  Gait and stance were normal.  X-rays of both feet were normal.

At a podiatry assessment on 24 May 2006 the CI complained of pain in the plantar aspect of each forefoot and thought that he could no longer function within his current L2 profile.  He also reported numbness in his feet.  Physical examination showed hammering of the lesser toes and visible corns on the 2nd toes.  Due to surgical correction, the 5th toes were no longer riding higher than the adjacent 4th toes and were no longer rubbing on the CI’s shoes.  Slight hammering of the great toes was also present.  Callus was present beneath the central metatarsal heads bilaterally.  Sensory testing of the toes to light touch was normal.

The MEB physical examination, recorded on DD Form 2808 Report of Medical Examination on 9 August 2006, 5 months prior to separation, noted a bilateral hallux valgus deformity and surgically corrected hammer toe deformities of the 5th toes.  The MEB NARSUM examination on 13 September 2006, 4 months prior to separation, noted complaints of foot pain due to wearing boots.  He could no longer run, perform sit-ups or push-ups or participate in sports.  The examiner rendered a diagnosis of bilateral foot pain secondary to pes planus, and stated that the condition was EPTS.  There was no VA examination performed proximate to separation.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral foot pain condition 30%, analogously coded 5276 (flatfoot, acquired).  An EPTS determination was made, but permanent service aggravation was acknowledged and a 10% deduction applied.  The VA rated the bilateral foot pain 0%, also analogously coded 5276 based on the CI’s STR.

The Board agreed with the PEB and VA that the 5276 coding pathway was appropriate in this case, and that “pronounced; marked pronation, extreme tenderness…” was not present; therefore the 50% rating for bilateral flatfoot was not warranted.  A 30% rating is characterized by “severe; objective evidence of marked deformity, pain on manipulation and use accentuated, indication of swelling on use, characteristic callosities.”  Members considered that characteristic callosities were evident, but debated if remaining deformities were best characterized as “marked” (the most significant was surgically corrected); and if the primary care examination 8 months prior to separation showing a normal gait, no foot tenderness, no painful motion and no swelling was consistent with the “pain on manipulation and use accentuated” or “swelling on use” stipulations.  It was concluded reasonable doubt did not favor this depiction, and the 30% rating therefore was not supported.  The 10% rating, described as “moderate,” was a more accurate descriptor of the bilateral foot condition.  The 5279 code (metatarsalgia) was applicable in this case, but offered no advantage to the CI since the maximum rating is 10% for a unilateral or bilateral condition under this code.

Next, the Board deliberated factors for a deduction for disability which may have existed at the time of entrance into active service.  Although the bilateral foot deformities were undoubtedly present prior to entry on active duty there was no record of prior symptoms or impairment.  The CI reported that no foot symptoms occurred until after service entry.  The 10% rating criteria under the PEB’s coding choice stipulates “pain on manipulation and use of the feet;” but there was no evidence of this at the time of service entry.  The Board members unanimously agreed that there was no ascertainable degree of disability existing at the time of entrance into active service; and, therefore, no rating deduction for EPTS factors should be recommended.  Board members noted that a 10% rating was appropriately recommended via the 5276 coding pathway (aforementioned), and that no EPTS deduction should be applied.  However, since the PEB’s 20% rating cannot be lowered, 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 bilateral foot pain condition.

BOARD FINDINGS:  In the matter of the chronic bilateral foot 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 20141115, 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 
XXXXXXXXXXXXXXXXXX, AR20160018343 (PD201404287)

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