RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00650
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20060927

SUMMARY OF CASE:  Data extracted from the available evidence of record reflected that this covered individual (CI) was an activated National Guard E4, Motor Transport Operator, medically separated for “arteriosclerotic heart disease,” with a combined disability rating of 10%. 

CI CONTENTION:  He was assigned a higher rating by the VA for his condition.  His condition continues to adversely impact his ability to perform daily activities.  The 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 - 20060830	VARD - 20071129	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Arteriosclerotic Heart Disease	7005	10%	Coronary Artery Disease	7005	60%	20061114	
Left Foot Pain	8725	---%	Heel Spurs, Bilateral	5299-5237	0%		
Bilateral Patellofemoral Syndrome	Not Unfitting 	Ligamentous Strain, Left Knee	5257	0%		
		Ligamentous Strain, Right Knee	5257	0%		
Hypertension		Hypertension	7107	0%		
Hearing Deficit, Bilateral High Frequency		Bilateral Hearing Loss	6100	0%		
Hyperlipidemia		No VA Placement	
Insomnia			
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  70%	

ANALYSIS SUMMARY:  

Arteriosclerotic Heart Disease.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s heart disease condition began in December 2004 after having noted an abnormal electrocardiogram (EKG) and random spells of sweating.  However he denied chest pain, dyspnea (shortness of breath), lightheadedness, fainting, or back pain.  Cardiology evaluation in May 2005 noted the CI had a history of a fast heartbeat without any cardiac symptoms and his EKG (electrocardiogram) was very consistent with an anteroseptal myocardial infarction, but its age was undetermined since he was asymptomatic.  An echocardiogram on 27 May 2005 demonstrated a kinetic (lack of movement) left ventricular apex, a left ventricular ejection fraction (LVEF) of 40% (normal greater than 50%), a moderately calcified posterior mitral annulus, and mild mitral, aortic, and pulmonary insufficiency.  

During a treadmill myocardial SPECT (single-photon emission computed tomography) profusion study on 31 May 2005 the CI exercised for 9 minutes and achieved 91% of his maximum peak heart rate.  There was no ischemia on the treadmill EKG, but there was a small to moderate sized distal anteroseptal stress-induced ischemia on the imaging with a small apical transmural infarction, mild left ventricular enlargement, abnormal wall motion, and a LVEF of 42%.  On 21 June 2005 the CI underwent cardiac catheterization, which revealed a kinetic left ventricle apex, a LVEF of 50%, total occlusion of the proximal left anterior descending artery and subtotal 95% eccentric narrowing of the proximal non-dominant, but large right coronary artery.   On 30 June 2005 stents were placed in the left mid anterior descending artery and in the proximal right coronary artery.  Occlusions were reduced to 0% stenosis.  Despite treatment, the 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 “coronary artery disease” for PEB adjudication.

A MEB NARSUM examination on 17 January 2006, 8 months prior to separation, performed for heel pain (see below) noted the CI’s aerobic capacity was limited by coronary artery disease.  On 4 April 2006 the CI underwent a treadmill stress EKG, which was normal, at which time he exercised for 7 minutes 45 seconds (1 minute 45 seconds into Stage 3 of the Bruce protocol), and achieved 93% of his predicted peak heart rate.  The nuclear SPECT perfusion scan revealed no ischemia and a large anterior, apical, septal infarction with a LVEF of 36%.  The cardiologist noted on 11 April 2006, the CI was doing well and was asymptomatic.  Medication recommendations included Lisinopril (for blood pressure), Lopressor (metoprolol for blood pressure and heart rate control), Plavix (clopidogrel, an anticoagulant), aspirin (an anticoagulant), and Zocor (simvastatin for hypercholesterolemia).  

At the MEB examination (recorded on DD Forms 2807-1 and 2808) dated 27 April 2006, 5 months prior to separation, the CI reported stent placement.  The examiner noted a history of an anterior wall myocardial infarction in 2005 (abnormal EKG) and checked normal for heart on the clinical evaluation.

At the 14 November 2006 VA Compensation and Pension (C&P) examination, performed 2 months after separation, the CI reported a history of placement of two stents and denied any shortness of breath, chest pains or palpitations.  On examination his height was 6 feet and weight was 238 pounds.  The heart tones were soft and regular as was the rhythm.  No murmurs were heard.  The apex was at the fifth interspace in the midclavicular line.  Blood pressure on sitting was 124/78 and standing 130/80.  A VA C&P addendum dated 30 July 2007 indicated an examiner estimated the metabolic equivalents (METs) to be 5.  At the 11 November 2007 VA internal medicine evaluation, performed approximately 13 months after separation, the CI reported a history of coronary artery disease without any symptoms of angina or congestive heart failure.  On examination the CI’s height was 72 inches and his weight was 236 pounds.  His pulse was 100 and blood pressure 160/98.  The heart rate and rhythm were regular without any murmurs and pulses were 2+ throughout.  The examiner’s diagnostic impression was coronary artery disease, status post stent placement.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating using the 7005 code (arteriosclerotic heart disease (coronary artery disease)), citing the CI exercised 1 minute 45 seconds into Bruce Protocol Stage III (9 METs).  The VA assigned a 60% rating using the 7005 code, based on the VA C&P examination 2 months after separation, citing an estimate of 5 METs.  Board members noted that although the CI had a history of an anteroseptal myocardial infarction, a decreased LVEF on several studies including a LVEF of 36% most proximate to separation, and placement of two coronary stents, he was able achieve a level of 9 METs on a stress test during which time he was asymptomatic.  

The Board took note of the VA rating, which was based on an estimate of 5 METs.  However, IAW VASRD §4.104 when “a laboratory determination of METs by exercise testing cannot be done for medical reasons, an estimation by a medical examiner of the level of activity (expressed in METs and supported by specific examples, such as slow stair climbing or shoveling snow) that results in dyspnea, fatigue, angina, dizziness, or syncope may be used.”  Board members did note that there was no indication that the CI could not undergo laboratory testing at the VA C&P examination or at a scheduled date thereafter.  Furthermore, the estimate of 5 METs was not supported by any specific examples; therefore, its use appeared to have been speculative.  However, because of multiple LVEFs between 30% and 50%, the CI warrants a 60% rating and no higher in the absence of chronic congestive heart failure or a workload of 3 METs or less or a LVEF lesion than 30%.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 60% for the arteriosclerotic heart condition, coded 7005.  

Left Foot Pain.  According to STRs and the MEB NARSUM, the CI’s left foot pain condition began in 2004 after frequent jumping in and out of trucks and wearing boots during deployment.  On 20 May 2004 the CI was noted to have a Haglund’s deformity (a bony enlargement on the back of the heel) of the foot and underwent surgical removal of an exostosis of the left calcaneus.  In September 2004 the CI had continued pain in the left foot/heel and was still wearing a boot walker.  The operative incision of the posterior lateral heel was well healed, but tender to palpation.  Despite stretching exercises, a night splint and Motrin (ibuprofen, a nonsteroidal anti-inflammatory drug (NSAID)), the CI continued to have left heel pain.  

In January 2005 the CI given soft orthotics and was offered options of an injection or cast, but did not want either.  Physical therapy range of motion (ROM) measurements of the left ankle in March 2005 were dorsiflexion less than or equal to 5 degrees (normal 20), plantar flexion 30 degrees (normal 45), and strength was in the 4-5/5 range.  Three weeks later dorsiflexion was 0 degrees and plantar flexion was 40 degrees.  Podiatric evaluation in February 2006 noted the CI had no foot pain prior to deployment.  Examination revealed venous stasis of the left foot, low arches bilaterally with pain on the plantar fascia bilaterally, a full ROM of the ankle/subtalar joint, and intense pain with light touch at the proximal scar on the left lateral heel.  The podiatrist raised the possibility of nerve entrapment versus hyperesthesia of the left heel scar, which may have been spinal or centrally mediated pain.  Conservative treatment was recommended and a steroid/anesthetic injection was given medial and superior to the scar of the left heel along with Relafen (Nabumetone, an NSAID) orally.  Pain management was also recommended in view of multiple head and back injuries in the past.  Despite treatment, the left foot 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 “bilateral heel spur” for PEB adjudication.

At the MEB examination (recorded on DD Forms 2807-1 and 2808) dated 27 April 2006, 5 months prior to separation, the CI reported surgery for a bone spur of the left calcaneus in May 2004 and  right and left foot pain.  The examiner noted a right heel spur and a scar of the left heel.

The MEB NARSUM examination on 17 January 2006, 8 months prior to separation, noted complaints of bilateral heel pain since December 2003 with radiographic (X-rays) studies indicating heel spurs.  Because he was unable to wear boots, the CI was medically evacuated and underwent a left calcaneal exostectomy (protruding bone) with Haglund’s resection.  There was no examination of the left foot noted in the NARSUM; nevertheless, the NARSUM author noted  pain was sharply localized and became worse with any kind of pressure placed on the area and was 0/10 (10 being the worst pain) with immobilization to 5/10 with walking while wearing shoes.  The NARSUM diagnosis was bilateral heel spur syndrome refractory to left exostectomy treated with ibuprofen.  

At the 14 November 2006 VA C&P examination, performed 2 months after separation, the CI reported improvement after surgery and continued to have occasional slight tenderness over the plantar surface of his feet with prolonged stranding.  He was able to ambulate without support and could climb stairs without difficulty, but wore inserts in his shoes for pes planus.  On examination he had a normal gait.  The ROM measurements of the ankles were dorsiflexion 15 degrees bilaterally and 20 degrees volar (plantar) flexion bilaterally.  A heel incision scar was well healed and there was moderate pes planus and slight discomfort on heel-toe walking.  At a VA C&P examination dated 25 August 2007, 11 months post-separation, the CI described the pain as sharp and burning.   The examiner noted the CI’s condition was “as least as likely as not, secondary to the calcaneal deformity for which he underwent surgical repair while in the service.”  Standing and walking caused the veteran to have a flare-up of pain, which was moderate to severe in degree and could last for several days. 

The Board directed attention to its rating recommendation based on the above evidence.  The PEB determined that the condition was not compensable, coded 8725 (posterior tibial nerve) mild or moderate neuralgia), citing left foot pain due to nerve entrapment after excision of symptomatic Haglund’s exostosis. The PEB noted “the original condition was developmental and not due to military service; the current symptoms are the consequence of appropriate medical treatment and as such are not compensable.”  The VA assigned a 0% rating using an analogous coded 5273 (Os calcis or astragalus, malunion), based on the VA C&P examination 2 months after separation, citing the absence of moderate deformity of the os calcis or astragalus.  

Board members noted that the CI did not have heel pain prior to deployment, but did have pain during deployment from wearing boots and jumping from trucks as well as post-deployment, post-surgery.  Therefore, although the CI had a developmental condition, there was service aggravation beyond natural progression since jumping from trucks accentuated and worsened the left Haglund’s deformity/exostosis.  Therefore, a rating for the condition is appropriate at 10% using code 8725 for mild or moderate neuralgia.  Although the CI was tender proximal to the scar, Board members did not feel the neuralgia was severe, which would warrant a 20% rating.  Board members considered use of code 5284 (foot injuries, other), however, the primary issue was pain both preoperatively secondary to the exostosis and postoperatively secondary to a possible nerve entrapment rather than an injury per se.  Therefore, the Board determined the use of code 5284 for rating is not applicable.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% for the left foot pain condition, coded 8725.  

Contended PEB Conditions:  Bilateral Patellofemoral Syndrome, Hypertension, Hyperlipidemia, and Insomnia.   The Board’s main charge is to assess the fairness of the PEB’s determination that the contended conditions were not unfitting.  None of the conditions were profiled or implicated in the commander’s statement or judged to fail retention standards.  There was no performance-based evidence from the record that any 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 any of the contended conditions and so no additional disability ratings are recommended.  

Contended PEB Condition:  Hearing Deficit, Bilateral High Frequency.  At the MEB examination on 11 May 2005 the CI had an average hearing loss of 42.5 dB on the right and 20 dB on the left.  In July 2005 the CI was issued an H3 profile for hearing loss with the restriction of no exposure to noise in excess of 85 dB.  The NARSUM indicated the CI had hearing loss related to weapons firing without hearing protection.  The commander’s statement in April 2006 indicated the CI had marked hearing problems and often needed instructions repeated to him either as a result of his poor hearing or failed comprehension.  Additional hearing examination results are in the chart below.  

HEARING	EXAM	MEB                                  ~5 Mos.  Pre-Sep	VA C&P                                     ~2 Mos. Post-Sep	
LEFT EAR	Average Hearing Loss	18 dB	 29 dB	
	Speech Discrimination	N/A	88%	
	Table VI / VIa	I	II	
RIGHT EAR	Average Hearing  Loss	18  dB	 30 dB	
	Speech Discrimination 	%	92 %	
	Table VI / VIa	I	II	
§4.85 RATING	Table VII	0%	0%	
(Average hearing loss is the sum of pure tone thresholds at 1000, 2000, 3000, and 4000 Hz divided by four)

Members discussed whether the hearing deficit was sufficient enough to be unfitting.  Because of the profile restriction, the CI was limited to noise less than 85 dB, which precluded exposure to weapons being fired or working near or on heavy, noisy machinery or aircraft, albeit adequate hearing protection as long as it was regularly and continuously used, might protect hearing to a certain extent.  However, the CI’s military occupational specialty (MOS) as a motor transport operator did potentially and actually expose him to noise in excess of 85 dB, especially when serving as a turret gunner.  After due deliberation, the Board agreed that the preponderance of the evidence with regard to the functional impairment of a bilateral high frequency condition favors its recommendation as an additionally unfitting condition for disability rating.  It is appropriately coded 6100 and meets the VASRD §4.85 criteria for a 0% rating.  

BOARD FINDINGS:  In the matter of the arteriosclerotic heart disease condition, the Board unanimously recommends a disability rating of 60%, coded 7005 IAW VASRD §4.104.  In the matter of the left foot pain condition, the Board unanimously recommends a disability rating of 10%, coded 8725 IAW VASRD §4.124a.  In the matter of the contended bilateral patellofemoral syndrome, hypertension, hyperlipidemia, and insomnia conditions, the Board unanimously recommends no change from the PEB determinations as not unfitting.  In the matter of the contended hearing deficit, bilateral high frequency condition, the Board unanimously agrees that it was unfitting and unanimously recommends a disability rating of 0%, coded 6100 IAW VASRD §4.85.  There were no other conditions within the Board’s scope of review for consideration.  

The Board recommends that the CI’s prior determination be modified as follows; and, that the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Arteriosclerotic Heart Disease	7005	60%	
Left Foot Pain	8275	10%	
Hearing Deficit, Bilateral High Frequency 	6100	0%	
COMBINED	60%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150602, w/attachments
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 
XXXXXXXXXXXXXXXXXX, AR20170000255   (PD201500650)

1.  Under the authority of Title 10, United States Code, section 1554(a), I approve the enclosed recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) pertaining to the individual named in the subject line above to re-characterize the individual’s separation as a permanent disability retirement with the combined disability rating of 60% effective the date of the individual’s original medical separation for disability with severance pay.  

2.  I direct that all the Department of the Army records of the individual concerned be corrected accordingly no later than 120 days from the date of this memorandum:

	a.  Providing a correction to the individual’s separation document showing that the individual was separated by reason of permanent disability retirement effective the date of the original medical separation for disability with severance pay.

	b.  Providing orders showing that the individual was retired with permanent disability effective the date of the original medical separation for disability with severance pay.

	c.  Adjusting pay and allowances accordingly.  Pay and allowance adjustment will account for recoupment of severance pay, and payment of permanent retired pay at 60% effective the date of the original medical separation for disability with severance pay.

	d.  Affording the individual the opportunity to elect Survivor Benefit Plan (SBP) and medical TRICARE retiree options.

3.  I request that a copy of the corrections and any related correspondence be provided to the individual concerned, counsel (if any), any Members of Congress who have shown interest, and to the Army Review Boards Agency with a copy of this memorandum without enclosures.

BY ORDER OF THE SECRETARY OF THE ARMY:

Enclosure

CF: 
(  ) DoD PDBR
(  ) DVA