RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00220
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20061021

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Petroleum Supply Specialist, medically separated for “multiple left foot fractures to 4th and 5th metatarsals to include Achilles tendon repair…pes cavus…” with a disability rating of 10%.

CI CONTENTION:  The CI contends for his left foot, both ankles and conditions not identified by either the MEB or PEB.  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 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 – 20060905	VARD – 20070228	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Multiple Left Foot Fractures to 4th and 5th Metatarsals to Include Achilles Tendon Repair…Pes Cavus…	5278	10%	Right Ankle Condition	5271-5003	10%	20061212	
			Left Ankle Condition	5271-5003	10%	20061212	
			Bilateral Pes Cavus, Left More than Right	5278	0%	20061212	
			Scars On The Left Ankle, Right Shoulder, Back and Left Arm	7804	0%	20061212	
Healed Stress Related Fractures, Left Metatarsals 4 & 5 Related to Dg 1	Not Unfitting	Old Fracture of the Left 4th and 5th Metatarsals	5283	10%	20061212	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  70%	

ANALYSIS SUMMARY:  

Multiple Left Foot Fractures to 4th and 5th Metatarsals to Include Achilles Tendon Repair…Pes Cavus.  According to service treatment records (STRs) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s left foot pain began in October/November 2003 after running and twisting his left ankle.  An X-ray series 1 month after the injury revealed a fracture of the 5th metatarsal, while 6 weeks post injury X-rays demonstrated fractures of the 4th and 5th metatarsals.  Despite casting, several month later he had pain and X-rays showed a fracture of the 4th metatarsal in another location.  After 8 weeks of a non-weight bearing cast, X-rays in December 2004 demonstrated complete healing of the fractures of the 4th and 5th metatarsals with no change in alignment or position; however, in the spring of 2005 he developed swelling of the left ankle and was diagnosed with a torn peroneal tendon and an X-ray series in April 2005 showed an attempted bony synostosis (fusion of adjacent bones) between the midshaft of the 5th metatarsal and base of the 4th metatarsal.  In October 2005 the CI underwent peroneal tendon repair and sheath reconstruction; however, post rehabilitation he was unable to run.  An L3 profile for left cavovarus foot and s/p peroneal tendon reconstruction was issued in November 2005.  A foot and ankle orthopedic surgeon recommended orthotics and a lateral heel wedge.  The examiner attributed the CI symptoms to a cavus foot deformity and opined the CI might be a candidate for a valgus calcaneal osteotomy. 

Despite treatment, the left foot pain condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and the CI was referred for an MEB.  The MEB forwarded “1. Cavovarus foot deformity (Pes cavus), bilateral, left slightly more severe than right; 2. Limitation of dorsiflexion, both feet secondary to above; and 3.  Healed stress related fractures, left metatarsals 4 & 5 (see below) related to Dg. 1” for PEB adjudication.

At the NARSUM examination on 3 May 2006, 6 months prior to separation, the CI was noted to have bilateral cavovarus (high arch and a turned inward heel) foot deformity, which was slightly more severe on the left that was tender along the lateral border of the foot on the 5th metatarsal.  There was a healed surgical incision along the posterior aspect of the lateral malleolus with otherwise normal skin.  Active dorsiflexion was 2 degrees on the left and 5 degrees on the right.  Plantar flexion was 45 degrees on the left and 50 degrees on the right; inversion was 25 degrees on the left and right; and eversion was 0 degrees bilaterally.  Bilateral lower extremity motor and sensory evaluations and reflexes were normal.  At the time of the examination the CI’s right foot was asymptomatic, and he had pain of his left foot over the base of his left 5th metatarsal bone lateral border when he was weight bearing.  The CI reported he was unable to run; shoe adjustments helped a little; orthotics did not help; custom made military boots could be worn; and Tylenol (acetaminophen, a pain reliever) was taken for pain control several times a week.  At the MEB examination on 22 May 2006, 5 months prior to separation, the CI reported intermittent pain of the left foot with walking about 7/10 (10 being the worst pain).  Physical examination showed bilateral cavovarus foot deformities with tenderness to palpation on left lateral malleolar area.  There was a scar on the left lateral malleolus.  The commander’s statement in June 2006 did not address the CI’s condition(s).  An examination on 30 October 2006, 9 days after separation, of the left foot revealed a high arch without tenderness, erythema, or joint swelling.  At an orthopedic examination on 28 November 2006 the CI walked with a normal gait and had tenderness on palpation over the left 4th and 5th metatarsals and was diagnosed with bilateral pes equinovarus (club foot) and status post fractures of the left 4th and 5th metatarsal bones.  X-rays of the left foot on 28 November 2006 showed an old healed fracture of the mid-shaft of the 5th metatarsal with mild deformity noted at the fracture site.   

At the 12 December 2006 VA Compensation and Pension (C&P) evaluation, performed 2 months after separation, the CI reported intermittent pain left foot with prolonged ambulation.  Orthotics provided some relief and he used bilateral ankle elastic braces for running.  Physical examination revealed bilateral pes cavus, left more than right, with bony prominence palpated at the left 5th metatarsal.  There was mild tenderness at the bilateral medial malleolus areas.  Dorsiflexion was 0-20 degrees (normal 20 degrees) bilaterally and plantar flexion was 0-45 degrees (normal 45 degrees) bilaterally with mild pain on motion with right ankle dorsiflexion between 15 degrees and 20 degrees.  There was severe varus bilaterally, left more than right.  The VA examination noted there was minimal bilateral osteoarthritis on X-rays in December 2006, although a report of X-rays of the right foot revealed no evidence of osteoarthritis on 12 December 2006.  In February 2007 the CI noted occasional foot pain after running, which was relieved by over-the-counter analgesics (Tylenol twice a month).  Orthopedic evaluation in May 2007 revealed bilateral cavus of the feet with metatarsal head callus with good subtalar motion present.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the multiple left foot fractures to 4th and 5th metatarsals to include Achilles tendon repair…pes cavus…condition 10%, coded 5278 (acquired claw foot (pes cavus)), citing AR 635-40 Appendix B-10 (Rating of disabilities aggravated by active service), with the determination that the condition had an EPTS factor that was undetermined.  The VA rated the multiple left foot fractures to 4th and 5th metatarsals to include Achilles tendon repair…pes cavus…condition 10% combining codes 5271-5003, (limited motion of ankle and degenerative arthritis), for the right ankle and 10% coded the same way for the left ankle based on the VA C&P examination 2 months after separation, citing painful motion.  The VA provided a 0% rating coded 5278, (acquired claw foot (pes cavus)), bilaterally based on the VA C&P examination 2 months after separation, citing ‘slight’ symptoms.  The VA additionally rated 10% coded 5283, (malunion of, or nonunion of tarsal, or metatarsal bones), based on the VA C&P examination 2 months after separation, citing ‘moderate’ symptoms.  Lastly, the VA rated the left foot surgical scar(s) at 0% under code 7804 (scar(s), unstable or painful), which is not in the scope of review.  

Board Approach to PEB Consolidated Rating. The PEB combined the multiple left foot bilateral left foot fractures to the 4th and 5th metatarsals to include the Achilles tendon repair and pes planus conditions as a single unfitting condition coded 5271-5003 and rated 10%. The approach by the PEB commonly reflected its judgment that the constellation of conditions was unfitting, and there was no need for separate fitness adjudications or implied adjudication that each condition was separately unfitting.  The Board’s initial charge in this case was directed at determining if the PEB’s approach of combining conditions under a single rating was justified in lieu of separate ratings.  When considering a separate rating for each condition, the Board considers each bundled condition to be reasonably justified as separately unfitting unless a preponderance of evidence indicates the condition would not cause the member to be referred into the DES or be found unfit because of physical disability.  When the Board recommends separate fitness recommendations in this circumstance, its recommendations may not produce a lower combined rating than that of the PEB.  The evidence for the left foot fractures, tendon repair, and pes cavus conditions was presented together above.  In this case, the fractures (also discussed below) had healed, but surgery according to notes in the STR was only performed on the left peroneal tendon and not the Achilles tendon, although the primary source operative report was not in the record.  The MEB did note the cavovarus foot deformity (pes cavus) bilaterally, there was no note that indicated all toes tended to dorsiflexion and while dorsiflexion was limited 6 months prior to separation, the VA examiner noted ankle dorsiflexion to be normal bilaterally 2 months post-separation.  From a probative value standpoint the VA examination was much closer to separation, which afforded sufficient time for healing without boots even though they were custom made and fit reasonably well.   The profile addressed only the left foot, while the commander’s statement did not address the CI’s condition(s) at all.  Therefore, while the left foot was the primary source of CI’s symptoms s/p metatarsal fractures, tendon repair, and cavovarus deformity and he reported at the NARSUM examination his right foot was asymptomatic, Board members determined that the left foot was the source of the disability that resulted in his separation.   Therefore, use of code 5284 (foot injuries, other) is more appropriate.  A moderately severe injury warrants a 20%, while a severe injury warrants a 30% rating.  However, at the time of separation, the CI’s fractures had healed as the tendon repair, but he still had pain with running, the disability of which does not rise to a 30% rating.  As noted above, by the time of the VA examination 2 months post-separation, the CI no longer had limitation of motion of either ankle, so that a separate rating for a condition not directly in the scope of review is not warranted.  Board members then considered the merits of use of code 5284 for a 20% rating (moderately severe) based on the history of multiple fractures, a torn, but repaired peroneal tendon, and cavovarus of the left foot versus a 10% rating (moderate), which offers no benefit to the CI, who already was rated 10% using code 5278.  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 Condition-Healed Stress Fractures, Left Metatarsals 4th & 5th.  The Board’s main charge is to assess the fairness of the PEB’s determination that the contended condition was not unfitting.  The contended condition was not profiled or implicated in the commander’s statement or judged to fail retention standards.  As noted above, X-rays in December 2004 demonstrated complete healing of the fractures of the 4th and 5th metatarsals with no change in alignment or position, while an X-ray series in April 2005 showed an attempted bony synostosis (fusion of adjacent bones) between the midshaft of the 5th metatarsal and base of the 4th metatarsal; however, X-rays of the left foot on 28 November 2006, 1 month after separation, showed an old healed fracture of the mid-shaft of the 5th metatarsal with a mild deformity noted at the fracture site.  There was no performance-based evidence from the record that the condition significantly interfered with satisfactory duty performance at separation.  After due deliberation, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the contended condition and so no additional disability rating is recommended.  

BOARD FINDINGS:  In the matter of the multiple left foot fractures to 4th and 5th metatarsals to include Achilles tendon repair condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended healed stress fractures, left metatarsals 4th & 5th condition, the Board unanimously recommends no change from the PEB determination 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 20150318, 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

19 DEC 2016

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for 
XXXXXXXXXXXXXXXXXX, AR20160018540 (PD201500220)

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