RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00316
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20090817

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Patriot Operator/Maintainer, medically separated for “moderate bilateral flexible pes planus resulting in bilateral lower extremity tibial stress reactions” and “low back pain,” rated 10% and 10%, respectively, with a combined disability rating of 20%.

CI CONTENTION:  Conditions rated under codes 5276 (pes planus and tibial stress reactions) and 5237 (low back pain) “were poorly rated.”  Reports these conditions have continued to worsen as indicated by the VA initially rating of 40% then later rated 60%.  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 - 20090508	VARD - 20090928	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Moderate Bilateral Flexible Pes Planus Resulting in Bilateral Lower Extremity Tibial Stress Reactions	5276	10%	Status Post Tibial Stress Fracture of the Bilateral Shins	5299-5262	0%	20090625	
			Pes Planus of the Bilateral Feet	5276	0%	20090625	
Low Back Pain	5237	10%	Lumbago with Allopathic Lesions	5237	0%	20090625	
Asthma	Not Unfitting	Asthma with Moderate Obstructive Respiratory Disease	6602	10%	20090625	
Insomnia	Not Unfitting	Primary Insomnia	9499-9423	10%	20090629	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:

Bilateral Flexible Pes Planus resulting in Bilateral Lower Extremity Tibial Stress Reactions.  According to service treatment records (STR), and the Medical Evaluation Board (MEB) Narrative Summary (NARSUM), the CI’s bilateral lower extremity conditions began in 2003 without report of a specific inciting accident or injury.  The MEB forwarded “bilateral lower extremity tibial stress reactions” and “bilateral flexible pes planus” for PEB adjudication.

At the MEB orthopedic consult examination dated 25 September 2008, 11 months prior to separation, the CI reported long standing bilateral (lower) extremity pain as well as bilateral foot pain with flat feet.  The CI denied any weakness, numbness, or tingling in his legs or feet.  Bone scan dated 11 September 2008 showed moderate bilateral tibial stress reactions and mild stress and post-traumatic changes at the knees and ankles, however there was no stress fracture noted.  Weight bearing X-rays of the knees and feet in September 2008 were normal.  Physical examination showed a non-antalgic gait with normal strength, reflexes, and sensation in the lower extremities.  Knee range of motion (ROM) with full at 0 degrees extension and 160 degrees flexion (normal 0-140) with no tenderness, laxity or instability.  Lower legs were normal with no tenderness or swelling.  Strength and pulses were normal.  Feet showed bilateral flexible pes planus with mild hind foot valgus.  There was no tenderness to the peroneal tendons or sheath, and the CI was “able to single toe, heel rise.”

The MEB NARSUM examination on 18 February 2009, 6 months prior to separation, noted complaints of flat feet with leg and knee pain.  Physical examination showed a non-antalgic gait.  Right leg exam showed bony tenderness along the proximal and middle-third of the tibia, normal skin examination and no calf tenderness.  There was full knee ROM without instability, and leg strength and sensation were normal.  A physical therapy formal ROM evaluation dated 24 February 2009, indicated right knee ROM of 0-125 degrees; left 0-128 degrees, and a 1+ Lachman’s test (minimal laxity) bilaterally.  Ankle ROM was not limited by pain with right ankle dorsiflexion to 10 degrees (normal 20) and plantar flexion to 42 degrees (normal 45) and left ankle dorsiflexion to 12 degrees and plantar flexion to 50 degrees.  The examiner noted the CI complained of 4/10 bilateral ankle pain and stated “pain does not appear to interfere with standing, sitting, or weight bearing from patient's time in the clinic.  Pain is the same 4/10 after completion of ROM measurements.”

At the 25 June 2009 VA Compensation and Pension (C&P) evaluation, performed 2 months before separation, the CI reported a 2 year history of painful flat feet (including weakness, stiffness, swelling, giving way and lack of endurance), tibial stress fractures since 2003, bilateral chondromalacia patella, (including weakness, stiffness, swelling, giving way and lack of endurance), that were elicited by physical activity or prolonged standing and relieved by rest.  The CI had inserts for his foot conditions.  Bilateral knee, ankle, and tibia-fibula X-rays were negative.  Right and left foot weightbearing X-rays were positive for pes planus.  Physical examination showed a normal gait.  There was “no detectable alteration in sensation, form or function in the right and left tibia and fibula.”  There was mild crepitus in both knees, with non-painful 0.5 cm instability on mediolateral movements of the knees (left greater than right).  The bilateral knees were otherwise within normal limits, with normal non-painful ROMs (0-140 degrees).  The right and left ankles were within normal limits (non-painful dorsiflexion 20 degrees, plantar flexion 45 degrees).  Examination of the feet and toes did not reveal any sign of painful motion, edema, disturbed circulation, weakness, atrophy of musculature or tenderness.  Arches were low/obscured and showed pes planus on weightbearing X-rays.  Palpation of the plantar surface did not reveal any tenderness, and the Achilles tendons showed good alignment.  Flexion and dorsiflexion of the toes did not induce pain.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the bundled lower extremity conditions at 10%, coded 5276 (flat foot, acquired), citing “rated for pain with use of feet.”  The VA rated bilateral pes planus 0%, also coded 5276 based on the VA C&P examination 2 months before separation, citing “mild symptoms relieved by built-up shoe or arch support.”  The VA rated tibial stress fracture of the bilateral shins 0%, analogously coded 5299-5262 (tibia and fibula impairment) based on the VA C&P examination 2 months before separation, citing “absence of malunion of the tibia and fibula with slight knee or ankle disability.”

The Board deliberated the probative values of the exams in evidence as well as the potential of unbundling the pes planus condition from the left and right tibial stress reactions.  There was no evidence of any stress fractures or malunion of the tibia or fibula.  The VA exam was closest to separation and adjudged to have the highest probative value for rating at separation.  The Board determined that there was insufficient evidence for independent unfitness or non-zero rating determinations for either the right or left tibial stress reactions.  There was no evidence of marked foot deformity, characteristic callosities or severe pes planus for any higher rating than that awarded by the PEB.  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 bilateral flexible pes planus resulting in bilateral lower extremity tibial stress reactions condition.

Low Back Pain.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s back condition began in January 2006 after being struck in the back by a heavy falling object.  Diagnostic imaging was negative.  The MEB forwarded “low back pain” for PEB adjudication.  At the MEB orthopedic consult examination dated 25 September 2008, 11 months prior to separation, the CI reported low back pain.  Physical examination showed normal strength, reflexes, and sensation in the lower extremities.  There was muscle spasm with a non-antalgic gait and normal heel and toe gait.  There was “full range of motion through his back” (with all numeric values above the VASRD normal for the specific plane of motion).  

The MEB NARSUM examination on 18 February 2009, 6 months prior to separation, noted complaints of low back pain without radiating symptoms or weakness.  Physical examination showed a non-antalgic gait.  Lower extremity strength, reflexes, and sensation were normal.  Heel and toe gait were normal.  Physical therapy formal ROM evaluation dated 24 February 2009, indicated painful motion with forward flexion of 75 degrees (normal 90) and combined ROM of 205 degrees (normal 240).  

At the 25 June 2009 VA Compensation and Pension (C&P) evaluation, performed 2 months before separation, the CI reported upper back stiffness and pain since 2005.  Thoracic and lumbosacral spine X-rays were negative.  Pain was increased with activity and decreased with muscle relaxers.  There were no periods of incapacitation.  Physical examination showed normal posture and gait with no back tenderness, spasm, painful motion, or radicular signs.  ROM was to normal VASRD values in all planes and there was no change on repetitive testing (negative DeLuca).

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 10%, coded 5237 (lumbosacral strain), citing forward flexion limited to 75 degrees.  The VA rated the back condition 0%, coded 5237 based on the VA C&P examination 2 months before separation, citing forward flexion of the thoracolumbar spine of greater than 85 degrees and/or combined ROM of the thoracolumbar spine greater than 235.

The Board agreed that a 10% rating, but no higher, was justified for limitation of flexion (greater than 60 degrees but not greater than 85 degrees) and/or combined ROM (greater than 120 degrees but not greater than 235 degrees) reported on the MEB/PT examination.  Although there was muscle spasm noted on the NARSUM exam, it was not severe enough to result in an abnormal gait or spinal contour, thus the next higher 20% rating was not justified on this basis.  There was no documentation of intervertebral disc syndrome (IVDS) with incapacitating episodes which would provide for a higher rating under that formula (for IVDS), or evidence of ratable peripheral nerve impairment which would provide for additional 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 low back pain condition.

Contended PEB Conditions:  Asthma and Insomnia.  The Board’s main charge is to assess the fairness of the PEB’s determination that the contended conditions were not unfitting.  Although both of these conditions were listed on the profile, neither of them was shown to require profile limitations.  In addition, neither of the conditions were implicated in the commander’s statement or judged to fail retention standards.  There was no performance-based evidence from the record that either of the conditions 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 either of the contended conditions and so no additional disability ratings are recommended.

BOARD FINDINGS:  In the matter of the bilateral flexible pes planus resulting in bilateral lower extremity tibial stress reactions condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the low back pain condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended asthma and insomnia 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 20150508, 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, AR20160018678 (PD201500316)

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