26061931
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00995
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20070917

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E2, Combat Medic Trainee, medically separated for “multiple stress fractures of the right and left metatarsals and stress changes of the left femoral neck” with a disability rating of 0%.  “Plantar fasciitis secondary to pes planus,” was determined as EPTS [existed prior to service] without permanent service aggravation). 

CI CONTENTION:  “Review all conditions.”  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 or non-compensable.  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 determination 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(s) 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 – 20070823	VARD - 20080924	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Multiple Stress Fractures, R & L Metatarsals & Stress Changes…L Femoral Neck	5022	0%	L Femoral Neck Stress Changes	5022-5252	10%	20080821	
			R 1st Metatarsal Stress Fx	5284	NSC	20080821	
			L 2nd Metatarsal Stress Fx	5284	NSC	20080821	
Plantar Fasciitis…	5399-5310	---%	Bilateral…Plantar Fasciitis	5299-5276	0%	20080821	
Adjustment Disorder	Not Unfitting	No VA Placement	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Multiple Stress Fractures, Right and Left Metatarsals and Stress Changes of the Left Femoral Neck.  The PEB combined bilateral metatarsal stress fractures and left femoral neck stress changes as a single unfitting condition coded 5022 (periostitis).  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.  The panel also noted that “bundling,” the combining of two or more major joints, may be permissible under the VASRD 5022 rating requirements, and that this approach does not compromise the VASRD §4.7 directive to choose the higher of two valid ratings.  The panel’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 panel 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 panel 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 bilateral metatarsal stress fractures and left femoral neck stress changes conditions is presented separately, with attendant recommendations regarding separate unfitness, and separate ratings, if indicated.  

According to service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI experienced pain in multiple locations in his lower extremities in February 2007.  Radiographic studies in July 2007 noted a 4-month history of increasing pain.  That study (X-ray) was normal, and was followed by a bone scan a week later.  The bone scan showed the right hip was normal, but stress changes were noted of the left hip (femoral neck).  Increased uptake of the right kneecap was noted which was consistent with prior trauma.  Stress fractures were noted of the right first metatarsal (the long foot bone behind the big toe) and left second metatarsal (i.e., same bone for the second toe).  Increased activity at the insertion of the right plantar fascia was also noted (where the foot arch meets the bottom of the heel; this is consistent with plantar fasciitis).  No additional clinical records or X-rays were in evidence prior to the NARSUM.  

At the MEB examination (recorded on DD Forms 2807 and 2808) dated 23 July 2007, the CI reported pain in both feet which began in basic training.  He also reported pain in the ankles and left knee, but did not report symptoms from either hip or the right knee.  The physical examination showed severe symptomatic flat feet (pes planus).  The MEB NARSUM was dated 3 August 2007.  It noted that the CI developed left hip and bilateral feet pain approximately 3 weeks into basic training.  The panel observed that the CI was actually seen for right rather than left hip pain.  It was also noted that the CI had been diagnosed with severe plantar fasciitis with pes planus.  On examination, he was noted to be walking with crutches.  Examination of the left hip showed tenderness around the groin, but the hip bone itself (greater trochanter) was not tender.  A provocative test for hip pathology (Patrick's test, aka FABER) was negative.  The CI could cross his legs and out-toe over 15 degrees.  Atrophy was absent.  Range of motion (ROM) was limited by pain with flexion of 90 degrees (125 normal), extension of 0 degrees (20 normal), external rotation 4 degrees (45 normal), abduction 45 (normal), and adduction 3 degrees (45 normal).  

The CI was seen in mental health 3 weeks later on 22 August 2007, less than 4 weeks prior to separation.  He was noted to be moving well without crutches.  

The VA Compensation and Pension (C&P) examination was performed on 21 August 2008, 11 months after separation.  The CI reported that he walked 0.6 miles a day (for exercise) and that he could walk 0.5 miles before limited by pain in his feet and hips.  In decreasing order of severity, he ranked the feet, right hip, and left hip.  He denied problems prior to enlistment and basic training.  Following separation, he work in security and walked 0.5 miles on patrol 3 times a night.  He did this for 3 months before deciding that it was too hard and seeking more sedentary work.  He did not use an assistive device or shoe inserts (orthotics).  On examination, he walked without a limp or pain behavior.  Shoe wear was normal and he could do a full squat and recover (without recorded difficulty).  His feet were noted to be pronated and the heels in valgus (clubfoot tendency).  The feet were tender to palpation on the top and bottom.  Flat feet were noted.  X-rays of the feet were negative for fractures or other significant pathology.  He was thought to have bilateral pes planus and plantar fasciitis.  There were no residuals from the stress fractures noted 13 months earlier.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 0% rating under the 5022 code (periostitis), for multiple stress fractures of the left and right metatarsals and stress changes of the left femoral neck.  It was noted that the CI was limited by pain from all affected areas which impaired weight bearing.  The panel observed that this suggested that the PEB found the “combined effect” of these conditions to be unfitting, but this language was not used, nor was it found in the records in evidence.  The panel then considered the conditions separately.  

The left hip condition was not reported by the CI as being symptomatic until it was noted in the NARSUM.  The panel observed that the NARSUM incorrectly indicated that the CI was symptomatic from the left hip since basic when in fact the right hip was symptomatic and the left only found incidentally on a bone scan.  At the time of the NARSUM, the CI was still using crutches, but 4 weeks later was walking normally with no crutches.  Following separation, the CI was able to work for 3 months as a security guard which required walking 1/2 mile 3 times a night.  His gait was again normal at the VA C&P examination.  The evidence does not support a finding that the left hip was unfitting at separation.  The panel observed that even if it were found unfitting, no more than a 0% rating could be supported.  

The panel next considered the bilateral metatarsal stress fractures.  These were identified on bone scan over 2 months prior to separation, but X-rays prior to separation were not in evidence.  As noted above for the hip, the CI was on crutches at the time of the NARSUM, but was off crutches and walking normally 4 weeks later.  Again, he was able to work as a security guard following separation.  The VA examination showed that the condition was resolved.  The evidence does not support a finding that either the left or right foot was separately unfitting at separation.  The panel again noted that even if either or both were found to be separately unfitting, a rating higher than 0% was not supported by the evidence.  

The VA assigned a 10% rating using a 5022-5252 code (periostitis - limitation of thigh flexion) based on the VA C&P examination 11 months after separation, citing the positive bone scan and painful and limited motion noted on the NARSUM.  The hip was not separately evaluated at the C&P examination nor were X-rays accomplished.  The VA determined that the right and left metatarsal stress fractures were not service-connected as the C&P showed that these conditions were resolved.  

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 adjudication for the multiple stress fractures of the left and right metatarsals and stress changes of the left femoral neck condition.  

Plantar Fasciitis Secondary to Pes Planus.  The PEB noted that there was compelling evidence that the current condition was an EPTS condition which was not permanently aggravated (PSA) beyond the normal progression the disease.  The panel reviewed the evidence.  The accession history and physical were not in evidence.  There were no clinical notes relating to the pes planus/plantar fasciitis condition.  The DD Form 2807 only noted that the feet hurt from the stress fractures and the plantar fasciitis without further elaboration.  Severe, symptomatic pes planus was noted on the DD Form 2808.  The MEB NARSUM noted pain at the sites of the metatarsal fractures and at the insertion of the plantar fascia bilaterally.  As noted above, the gait was subsequently normal at a mental health evaluation 1 month prior to separation and at the VA C&P examination.  The panel found no evidence in the record to either support or refute the PEB adjudication that the bilateral pes planus and plantar fasciitis conditions were both EPTS and not service aggravated.  Accordingly, the panel concluded that there was insufficient cause to recommend a change in the PEB fitness determination for these contended conditions.  

Contended PEB Conditions:  Adjustment Disorder.  The panel’s main charge is to assess the fairness of the PEB’s determination that the contended adjustment disorder conditions was not unfitting.  It was not profiled or implicated in the commander’s statement.  It was judged to meet retention standards.  There was no performance-based evidence from the record that this condition significantly interfered with satisfactory duty performance at separation.  After due deliberation, the panel concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the contended adjustment disorder condition and so no additional disability rating is recommended.  

BOARD FINDINGS:  In the matter of the bilateral metatarsal stress fractures and left femoral neck stress changes condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  In the matter of the bilateral pes planus and plantar fasciitis condition, the panel unanimously recommends no change in the PEB adjudication.  In the matter of the contended adjustment disorder condition, the panel unanimously recommends no change from the PEB determination as not unfitting.  There were no other conditions within the panel’s scope of review for consideration.  The panel, therefore, recommends that there be no modification or re-characterization of the CI’s disability and separation determination.  

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150609, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

 XXXXXXXXXXXXXXXXXX. 

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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,