RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00241
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20070315

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Cannon Crewmember, medically separated for “chronic left foot and ankle pain,” with a disability rating of 20%.  

CI CONTENTION:  The CI’s left foot and ankle continues to worsen and negatively impacts daily living.  Additionally, the CI requests the board consider multiple conditions not in scope for this board.  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 - 20061130	VARD - 20070425	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Left Foot and Ankle Pain	5284	20%	S/P Fractures, Left Foot with Posttraumatic Degenerative Joint Disease Midfoot	5003-8523	20%	20070306	
			S/P Injury, Left Ankle	5271	10%		
			Scars, Anterior and Dorsal Aspect, Left Foot	7805	0%		
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Chronic Left Foot and Ankle Pain.  The PEB adjudicated the foot and ankle pain as a single unfitting condition coded 5248 (foot injuries, other) and rated 20%.  The approach by the PEB not uncommonly 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 therefore 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 foot and ankle conditions are presented below, with attendant recommendations regarding separate unfitness, and separate rating if indicated. 

According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s left foot and ankle pain condition began after a nighttime airborne jump in March 2004.  The injury resulted in a spiral fracture of the 2nd ray (metatarsal), comminuted fracture of a mid-foot bone (intermediate cuneiform), and ligamentous instability (Lisfranc dislocation).  He was diagnosed with “significant” osteoarthritis of the mid-foot.  The X-ray of the left ankle showed no evidence of arthritic or inflammatory changes.  Despite treatment, the foot and ankle condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and the CI was referred for MEB.  The MEB forwarded “chronic left foot and ankle pain and arthritis status post ORIF of second metatarsal with intermediate cuneiform comminution and Lisfranc ligament disruption” for PEB adjudication.  

At a podiatry visit in July 2006, 8 months prior to separation, the CI reported left foot pain with weight bearing and with moderate to high impact activities.  The physical examination showed crepitus and tenderness to palpation as well as moderate crepitation with manipulation.  There was a mid-foot deformity causing deviation.  The examiner diagnosed post-traumatic degenerative joint disease of the left mid-foot.  

At the MEB examination (recorded on DD Forms 2697, 2807 and 2808) in August and September 2006, 6 and 7 months prior to separation, the CI reported pain with walking, inability to bear full weight, limping, and lower extremity joint pains.  The physical examination showed an antalgic gait, pain with inversion, loss of dorsiflexion and plantar flexion, and inability to perform a heel raise due to severe pain.  There was “intact” neurologic testing with 5/5 strength of the lower extremity muscles (extensor hallucis longus for dorsiflexion; peroneals for eversion and dorsiflexion; anterior tibialis for dorsiflexion and inversion).  

At the MEB NARSUM examination dated 30 October 2006, the examiner referenced the 2808 examination and physical therapy range of motion (ROM) examination dated 19 September 2006 that documented ankle dorsiflexion of 8 degrees (normal 20), plantar flexion of 30 degrees (normal 45), and pain reported with all ankle motion.  

At the 6 March 2007 VA Compensation and Pension (C&P) evaluation, 9 days prior to separation, the CI reported pain, limp, and inability to carry his own body weight.  The physical examination showed a normal gait without use of assistive devices or corrective shoe inserts; and normal appearing arches with no evidence of clawed feet or hammertoes.  There was limitation of dorsiflexion (10 degrees) and plantar flexion (20 degrees).  The CI was unable to stand on his left foot due to weakness and lack of endurance, and the examiner opined that this was due to ankle weakness and an asymmetric left leg size with subsequent impact on ROM.  There was “considerable weakness in the movement of the toes… related to disturbance in the deep peroneal and sural nerves,” but no evidence of painful motion of the feet and toes.  Radiographic evaluation documented a healed fracture and post-surgical changes of the foot and a normal ankle.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the chronic left foot and ankle pain condition 20%, coded 5284 (foot injuries, other), citing moderately severe foot injury.  The VA rated the left foot condition 20%, coded 5003-8523 (degenerative arthritis-paralysis of anterior tibial nerve (deep peroneal)), based on the VA C&P examination 9 days before separation, citing an incomplete paralysis of foot movements.  The VA also rated the left ankle condition 10% coded 5271 (ankle, limited motion of), citing moderate limitation of motion.   
 
It is clear that there are various related diagnoses contributing to the disability in this case; and, members first agreed that there were not separate conditions which could be reasonably justified as separately unfitting; nor would separate ratings be achievable without violation of VASRD §4.14 (avoidance of pyramiding).  The ankle limitation of motion recorded at the time of the MEB NARSUM examination was mild to moderate.  All members agreed the limitation of motion was not ‘marked’ to support the next higher rating under 5271.  The Board considered whether rating under the VASRD code for other foot injuries (5284) provided for a higher rating (§4.7), however, all Board members agreed that the ‘severe’ level (30%) was not supported.  There was no evidence of malunion or nonunion of the tarsal or metatarsal bones in support of a higher rating under 5283.  There was no evidence of unilateral claw foot (5278) or flatfoot (5276) for a higher rating.  Rating under code 5277 is for a bilateral condition and does not provide a higher rating for evidence of weakness.  Although lower extremity weakness was found at the VA C&P examination, there was no STR evidence to support a duty limiting nerve impairment for consideration of a separately unfitting 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 left foot and ankle pain condition.  

BOARD FINDINGS:  In the matter of the chronic left foot and ankle 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 20150130, 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 XXXXXXXXXXXXXXXXXXXXX, AR20170002575 (PD201500241)

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