RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX.	CASE:  PD-2015-00806
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20080826

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3, Motor Transport Operator, medically separated for “right posterior tibial tendonitis” with a disability rating of 10%.  

CI CONTENTION:  “It affects my ability to function properly at work.  Difficultly sleeping due to pain (R) and (L) feet.”  The complete submission is at Exhibit A.  

SCOPE OF REVIEW:  The panel’s scope of review is defined in DoDI 6040.44.  It is limited to review of disability ratings assigned 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 panel’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 panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The panel’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 panel 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 panel 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 - 20080422	VARD - 20150918	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Posterior Tibial Tendonitis	5024	10%	Right Posterior Tibial Tendonitis	5262	NSC	STR	
			Stress Fracture 1st Metatarsal (Right Foot)	5283	0%	STR	
Left Foot Pain	Not Separately Unfitting	Left Posterior Tibial Tendonitis	5262	NSC	STR	
		Stress Fracture 1st Metatarsal (Left Foot)	5283	0%	STR	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY:  

Right Posterior Tibial Tendonitis (Subsuming Left Foot Pain).  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s onset of bilateral foot pain began in October 2006 during basic training. The initial clinical complaints and more of the evaluation were directed at the right foot and ankle.  Radiographic (X-ray) studies of the right ankle were normal, but a stress fracture of the right foot was suspected and a bone scan was recommended.  There were no X-rays in evidence of the left foot or ankle.  A bone scan demonstrated bilateral stress changes and possible stress fractures of the first metatarsals, although the working diagnosis was tendonitis as per the MEB submission below.  There were no clinical entries in the available STR that were probative to range of motion (ROM), functional impairment, relative severity of one foot versus the other, or other VASRD rating criteria.

The 23 January 2008 podiatry NARSUM examination, 7 months before separation, documented a chief complaint of “bilateral foot pain” with pain rated “slight and frequent” and aggravated by prolonged standing, walking, and load-bearing.  The physical examination recorded bilateral foot tenderness with normal neurovascular findings (5/5 bilateral strength).  The initial NARSUM examination, as well as the MEB’s DD Form 2808, Report of Medical Examination, documented grossly normal bilateral ROM.  Upon PEB request, formal goniometric measurements were provided (3 months later).  These were recorded as dorsiflexion to 5 degrees (normal 20) for the right foot and 10 degrees for the left, and bilateral plantar flexion to 30 degrees (normal 45); specifying painful motion but no ROM degradation with repetition.

The permanent L3 profile listed “both feet,” and the commander’s performance statement was not probative to separate fitness implications of either foot (or whether unilateral or bilateral).  The CI failed to report for a scheduled VA examination, and there was no temporally probative evidence after separation.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB’s 10% rating for the right foot under code 5024 (tenosynovitis, defaulting to criteria of code 5003 [degenerative arthritis]) cited “limitation of motion.”  The PEB adjudicated the left foot condition as not separately unfitting, stating, “His primary problem is his right foot, based on multiple health record entries.”  The VA, based on the same STR evidence, adjudicated two separate diagnoses for each foot as charted above.  The tendonitis diagnoses were not service connected, citing uncertainty if they were pre-existing to service and the lack of an enlistment examination, along with failure to show for a scheduled VA examination.  The metatarsal stress fracture diagnoses were separately coded 5283 (metatarsal bones, malunion or nonunion), for which the minimum 10% rating requires “moderate” disability.  The VA rating decision assessed “mild or no symptoms,” justifying 0% determinations for each foot under that code.

The panel first considered whether the left foot condition fell within the panel’s scope of authority as defined above.  Although it was determined to be not unfitting and was specifically contended by the CI, the panel agreed that, since it was incorporated in the MEB’s single submission and treated as a bilateral condition in the NARSUM, it was integral to the panel’s overall recommendation and fairly within its scope for consideration.  Having so agreed, the panel’s first consideration was the fairness of the PEB’s decision that the left foot was not separately unfitting.  

The available STR evidence did not fully corroborate the PEB’s conclusion that the right foot condition was the dominant cause of the unfitting impairment; but, it appeared likely that the PEB had access to clinical evidence that was not included in the panel’s file; and, the available records were dominantly focused on the right foot.  Although the NARSUM, the MEB submission, and the profile did not differentiate separate acuity for each foot, it remained that there was no performance-based evidence (including the commander’s statement) that would counter the PEB’s conclusion.  In consideration of the above standard, the panel concluded that there was not a preponderance of evidence that the left foot alone interfered with duty requirements to an extent that would have resulted in termination of service; thus, it was appropriately adjudicated by the PEB as not unfitting and therefore not rated.

With regards to the panel’s rating recommendation for the unfitting right foot condition (subsuming the ankle), the panel considered alternate rating under code 5271 (ankle limitation of motion) that confers a 20% rating for “marked” limitation; but, the panel agreed that this criterion was not reasonably supported by the above ROM evidence.  The only other codes that could be considered in this case were analogous application of the VA’s code 5283 or analogous 5284 (foot injuries, other).  Both of these codes, however, designate “moderately severe” disability for a higher 20% rating; and, the panel agreed that the functional impairment in evidence did not reasonably support that criterion.  There was thus no applicable code under VASRD §4.71a that would justify a rating higher than the 10% adjudicated by the PEB.

After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded that there was insufficient cause to recommend a change in the PEB adjudications of the right posterior tibial tendonitis and left foot pain conditions (subsuming ankles).

BOARD FINDINGS:  In the matter of the right posterior tibial tendonitis condition (subsuming the ankle) and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  In the matter of the contended left foot pain condition, the panel unanimously recommends no change from the PEB determination as not unfitting.  There are no other conditions within the panel’s scope of review for consideration.  The panel, therefore, recommends that there be no modification or no re-characterization of the CI’s disability and separation determination.  

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

AR20170007393, XXXXXXXXXXXXXXXXXX. 

Dear XXXXXXXXXXXXXXXXXX:

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found your separation disability rating and your separation from the Army for disability with severance pay to be accurate.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed), and I accept its recommendation.  I regret to inform you that your application to the DoD PDBR is denied.  

	This decision is final.  Recourse within the Department of Defense or the Department of the Army is exhausted; however, you have the option to seek relief by filing suit in a court of appropriate jurisdiction.

Sincerely,