RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00013
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20080227

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-2, Indirect Fire Infantyrman, medically separated for a left foot condition, rated at 10%. 

CI CONTENTION:   “Please consider all 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:  

Admin/PDA Correction PEB - Dated 20080923	VA* - Based on Service Treatment Records (STR)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Metatarsalgia, Left Foot	5279	10%	Posterior Tibial Dysfunction and Painful Accessory Navicular of the Left Foot	5299-5284	10%	STR	
Irritable Bowel Syndrome	Not Unfitting	Irritable Bowel Syndrome and Gastritis	7307-7319	NSC	STR	
Asymptomatic Microscopic Hematuria	Not Unfitting	No VA Placement	
Prediabetes	Not Unfitting	No VA Placement	
Hyperlipidemia	Not Unfitting	No VA Placement	
History of simple Cysts in the Spleen and Kidney	Not Unfitting	Splenic Cyst	7599-7529	NSC	STR	
Other MEB/PEB Conditions x 0 (Not In Scope)	Other x 8 	
RATING:  10%	RATING:  10%	
*Derived from VA Rating Decision (VARD) dated 20080729 (most proximate to date of separation [DOS]).  

ANALYSIS SUMMARY:  

Metatarsalgia, Left Foot Condition.  The narrative summary (NARSUM) noted the CI injured his left foot during a long march when he stepped on a rock and rolled his foot.  The CI’s military enlistment physical on 10 March 2005 documented normal arches bilaterally.  However, service treatment records (STR) as early as April 2005 recorded pes planus (flat foot) of both feet, and left foot and ankle X-rays on 1 June 2005 noted flat foot with a bony deformity of the talus bone (tarsal bone that meets the tibia/fibula at the ankle joint) and bony density adjacent to the navicular and calcaneus joints (tarsal bones).  A bone scan, dated 23 September 2005, showed multiple areas of stress reaction in the foot and ankle.  Following this, the CI was deployed and the foot pain continued, although he successfully completed the deployment.  When he re-deployed, further evaluation by orthopedics and podiatry diagnosed pes planus and posterior tibialis tendon dysfunction (supports the arch of the foot), with a bony mass on the medial aspect of the foot, thought by the podiatrist to be an accessory navicular bone (accessory bones are congenital and often asymptomatic).  Left foot X-rays on 20 November 2006 noted bone spurs of the talus, without evidence of fracture, dislocation, or other degenerative changes and ankle X-rays showed no other abnormalities of the ankle joint.  A podiatry evaluation on 6 February 2007 documented tenderness of the foot, without swelling or callus on the bottom of the foot.  Magnetic resonance imaging (MRI) scans of the left foot and ankle, dated 12 February 2007, were normal without tendon or ligament injury.  Despite treatment including orthotics, anti-inflammatory medications, and pain medication, the foot pain persisted.  The podiatrist indicated there was a low probability of improvement from surgery and an MEB was recommended. 

The MEB podiatry evaluation, on 9 July 2007 and 8 months before separation, noted a tender bony prominence on the medial aspect of the left foot and tenderness to palpation of the ankle.  There was a decreased arch on the left compared to the right, with pronation and valgus heel position (foot deviating outward) with weight bearing, and decreased strength and tenderness with inversion of the foot.  At the MEB examination, dated 14 November 2007 and 3 months before separation, the CI reported chronic left foot pain aggravated by weight bearing activities.  The MEB physical examination noted a “mild antalgic gait.”  The range of motion (ROM) of the ankles was normal, except for right dorsiflexion of 5 degrees (normal 20) and left dorsiflexion of 3 degrees, limited by pain.  

The CI failed to report to the scheduled VA Compensation and Pension (C&P) examinations on 10 March 2008 and 12 July 2008.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the left foot condition 10%, coded 5279 (metatarsalgia).  The VA rated the left foot condition 10%, coded 5299-5284 (analogous to other foot injury), and noted the rating was based upon service medical records because the CI had not attended two scheduled C&P examinations.  The Board agreed that the evidence in record supports a 10% rating for the left foot condition either coded according to 5003 (degenerative arthritis) criteria for a single joint or group of minor joints; as 5299-5284 for moderate foot injury; or as 5299-5276 (analogous to acquired flatfoot) for moderate pes planus, with pain on manipulation or use of the feet, whether bilateral or unilateral.  The Board reviewed to see if a higher evaluation was supported with any of these codes.  However, a 10% rating is the highest available rating coded as 5279 and there was no evidence of severe pes planus with marked deformity and swelling on use or characteristic callosities for higher rating coded as 5276.  The Board noted that the rating criteria of 5284 are subjective, with 10% rating for “moderate,” 20% for “moderately severe,” and 30% for “severe” foot injury.  Member consensus was that the foot pain with “mild antalgic gait” was best characterized as a “moderate” and not “moderately severe” foot injury.  The Board reviewed to see if a higher evaluation was supported with any other applicable code.  However, there was no evidence in the record of claw foot (5278) or malunion or non-union of the tarsal or metatarsal bones (5283), the only VASRD foot codes with ratings greater than 10%.  Also, there was no diagnosis of ankylosis of the tarsal bones for a higher rating utilizing VASRD code 5272 (ankylosis of the foot).  The Board also deliberated whether the left ankle should be additionally or alternatively rated for limited ankle ROM.  However, the unfitting condition was foot pain and the CI did not have any documented injury or diagnosis specific to the ankle joint.  The decreased ankle ROM noted at the MEB exam was comparable on the unaffected right side, supporting that it was related to the congenital pes planus.  Therefore, the Board determined that in this case neither rating the CI’s unfitting condition as an ankle condition, nor providing an additional rating for the ankle was warranted.  Thus, the Board determined that the evidence supports a 10% rating for the foot condition and no higher.  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 left foot condition.

Contended PEB Conditions. Irritable bowel syndrome (IBS), microscopic hematuria blood in urine, pre-diabetes, hyperlipidemia, history of simple cysts of the spleen and kidney conditions.   

IBS.  The NARSUM noted the CI underwent a complete evaluation for abdominal pain and diarrhea by gastroenterology in 2007 and the diagnosis was IBS.  Documentation in the STR indicated the CI was on various medications for IBS and gastroesphageal reflux, with improvement in the IBS symptoms.

Microscopic hematuria.  The NARSUM noted that the CI underwent a comprehensive evaluation for asymptomatic microscopic hematuria in May 2007.  The CI had been previously evaluated for hematuria years earlier with a similarly negative investigation.  The kidney specialist stated that the hematuria was not normal, but the long history without symptoms and otherwise normal kidney function was reassuring.  The specialist recommended further evaluation, but indicated that if a cause was not identified, kidney biopsy was not recommended at the time.  According to the NARSUM following this evaluation, the kidney specialist advised the CI that there was “nothing to worry about.”  

Pre-diabetes.  The NARSUM noted that on routine screening bloodwork for the MEB, the CI’s blood sugar was elevated, however, a hemoglobin AIC was normal, which reflected blood sugar control over an approximate 3-month period.  A clinic note on 3 July 2007 indicated that the CI may not have fasted long enough in advance of his bloodwork.  

Hyperlipidemia.  The NARSUM noted that the routine MEB bloodwork also pointed to mildly elevated total cholesterol and triglycerides.  However, as mentioned above, the CI may not have been in a fasting state (the lipid levels, particularly the triglycerides would not be interpretable after eating).

History of kidney and spleen cysts.  The NARSUM noted that cysts of the left kidney and spleen were incidental findings on an abdominal computed tomography (CT) scan performed during the evaluation for upper right side abdominal pain.  A follow-up CT performed with contrast indicated two cysts in the spleen and several bilateral small renal cysts, which appeared to be benign (also referred to as simple).  Ultrasound showed a cyst in the spleen, but no cysts were noted in the kidneys.

The Board noted that hyperlipidemia and pre-diabetes refer to abnormal laboratory tests and are not conditions or circumstances causing any physical disability or impairment in military duties, and are therefore not unfitting or compensable.  The irritable bowel syndrome (IBS), microscopic hematuria, and simple cysts of the spleen and kidney 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 the any of the contended conditions and so no additional disability ratings are recommended.

BOARD FINDINGS:  In the matter of the left foot condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended IBS, microscopic hematuria, pre-diabetes, hyperlipidemia, and history of simple cysts of the spleen and kidney 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.  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 20141223, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

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 XXXXXXXXXXXXXXXXXXXXX AR20160011861 (PD201500013)

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