RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00593
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20090108

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a Reserve E1, Basic Trainee, medically separated for “bilateral foot injuries,” with a disability rating of 20%.  

CI CONTENTION:  “Review all conditions.”  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 on 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 – 20081215 	VARD - 20110623	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Foot Injuries	5284	10%	Bilateral Feet Calcaneal Stress Fractures	5299-5273	NSC	20110607	
		10%					
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  NSC	

ANALYSIS SUMMARY:  

Bilateral Foot Injuries.  According to service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s bilateral heel pain condition began in May 2008 during the second week of basic training after increased running and wearing boots.  On 29 May 2008 the CI had tenderness on palpation of both heels, which was treated with Motrin (ibuprofen, a nonsteroidal anti-inflammatory drug (NSAID)).  On 4 June 2008 tramadol (an opioid-like medication) and crutches were added to the treatment protocol since the CI also had left knee pain, which is not in the scope of review.  X-rays of the feet on 5 June 2008 were normal.  A bone scan on 12 June 2008 revealed findings consistent with stress fractures of the calcanei (heel bones) bilaterally. Treatment consisted of calcium with Vitamin D, physical therapy education, and convalescent leave.  X-rays on 25 July 2008 demonstrated band-like sclerosis at the bilateral posterior calcanei consistent with bilateral calcaneal stress fractures.  The CI reported no improvement after convalescent leave and noted that rainy weather caused pain in the feet.  In September 2008 pool therapy was added to her treatment.  X-rays on 5 September 2008 revealed resolved stress fractures of the calcanei.  On 17 November 2008 the CI reported bilateral calcaneal pain of 4/10 (10 being the worst pain).  On a podiatry examination there was tenderness on palpation of the posterior aspects of the heels.  Her gait and resting calcaneal stance were normal as was the remainder of the examination of her feet.  No surgical procedure was indicated.  Despite treatment consisting of profiles, convalescent leave for 60 days, pain medications, physical therapy and arch supports, and the bilateral foot injuries condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and the CI was referred for a MEB.  The MEB forwarded “bilateral calcaneal stress fractures” for PEB adjudication.  

At the MEB examination (recorded on DD Form 2807-1 and 2808) dated 22 October 2008, less than 3 months prior to separation, the CI reported  “stress fracture both heels.”  The examiner checked normal for the clinical evaluation of the feet, circled normal arch, and listed “healed bilat[eral] calcaneal” in the summary of defects and diagnoses.  At the NARSUM examination dated 17 November 2008 she had tenderness to palpation of bilateral posterior calcanei.  There was no erythema, edema, ecchymosis, scars, cysts or lesions.  She had normal arch height and had full range of motion (ROM) of the ankle, subtalar, and metatarsophalangeal joints bilaterally. On stance she had no excess pronation and her gait was fairly normal and symmetric without limping.  

At the 7 June 2011 remote VA Compensation and Pension (C&P) evaluation, performed 29 months after separation, the CI reported pain, described as squeezing, burning, and aching, in both heels constantly at a level of 9/10 and noted difficulty with weight bearing activities.  She was able to stand 15-30 minutes and did not require any type of support with her shoes.  The physical exam showed her ankle ROMs were normal and examination of the feet did not reveal painful motion, edema, disturbed circulation, and weakness, atrophy of the musculature, heat, redness or instability.  There was slight tenderness of the plantar surfaces of the feet bilaterally. Pes planus was present.  Bilaterally, there was a moderate degree of valgus present, which could be corrected by manipulation.  There was also forefoot/midfoot malalignment of a moderate degree, which could also be corrected by manipulation.  Additionally, there was deformity of inward rotation of the superior portion of the os calcis, deformity of medial tilting of the upper border of the talus, and deformity of marked pronation.  There was no pes cavus, hammer toes, metatarsalgia, hallux valgus, or hallux rigidus.  An X-ray series of the feet dated 7 June 2011 with and without weight bearing demonstrated intact feet without evidence of acute lesions or arthritic changes and with well-maintained plantar arches.  

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB assigned a 20% combined rating, consisting of the right foot 10% and the left foot 10%, under code 5284 (Foot injuries, other:), citing foot pain due to calcaneal stress fractures.  The condition was rated as moderate because of preserved foot function permitting walking and standing, albeit with pain that prevented completion of training.  The VA assigned a Not Service Connected, Not Incurred/Caused by Service rating using an analogous 5299-5273 code (Os calcis or astragalus, malunion of:) based on the VA C&P examination 29 months after separation, citing normal X-rays of both feet and heels.  Board members noted that although the PEB noted a combined rating of 20%, it further delineated the right foot and left foot at a 10% rating for each foot.  Board members then considered whether either or both of the CI’s heel pain conditions rose to a moderately severe level using code 5284 or had a marked deformity using code 5273 with a 20% rating for each foot.  Because the bilateral fractures had healed and objectively there was only tenderness on palpation of the heels, no deformities of either foot, no surgery and no significant injury, members did not believe either foot rose to the level of moderately severe or having a marked deformity at the time of separation.  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 foot injuries condition.  

BOARD FINDINGS:  In the matter of the bilateral foot injuries 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 20150606, 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, AR20170000273 (PD201500593)

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