RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01059
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20050624

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E1, Trainee, medically separated “chronic bilateral heel pain” with a disability rating of 0%.

CI CONTENTION:  “Review all conditions.”  The CI’s 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 - 20050610	VARD - None	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Bilateral Heel Pain	5099-5003	0%					
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  NA	

ANALYSIS SUMMARY:  

Chronic Bilateral Heel Pain.  The PEB assigned a 0% rating for chronic bilateral heel pain and coded analogously to 5003 with application of the US Army Physical Disability Agency (USAPDA) pain policy and AR 635-40 B24.f.  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 5003 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 chronic bilateral heel pain conditions is presented below, with attendant recommendations regarding separate unfitness, and separate rating if indicated.

According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s heel conditions began in February 2005 during basic training without specific injury.  Both heels were tender with the squeeze test and bilateral heel X-rays showed an early right calcaneal stress fracture.  The CI was diagnosed with right heel stress fracture and placed on 30 days convalescent leave and physical rehabilitation, but the bilateral heel pain persisted.  A podiatry evaluation noted a history of bilateral calcaneal stress fractures, but noted persistent stress fracture changes on X-rays of the right heel only.  The MEB forwarded “bilateral calcaneal stress fractures that were sustained while performing basic training activities” for PEB adjudication.  

The permanent profile listed chronic bilateral calcaneal stress fractures.  There was no commander’s statement; the CI was a basic trainee.  

The MEB NARSUM examination on 20 May 2005, 1 month prior to separation, noted complaints of bilateral heel pain, right greater than left.  Physical examination showed mild swelling of both ankles.  There was tenderness to palpation of both heels, right greater than left.  The examiner noted there were no other findings on physical exam.  According to the MEB NARSUM examiner right and left foot X-rays showed calcaneal stress fractures and the diagnosis was bilateral calcaneal stress fractures.  The MEB examiner indicated the stress fractures should continue to improve, and there was no surgical indication.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the chronic bilateral calcaneal stress fractures condition 0%, coded 5099-5003 (analogous to degenerative arthritis), citing the US Army Physical Disability Agency (USAPDA) pain policy.  

The panel first considered if the chronic bilateral heel pain conditions remained separately unfitting when separated from the PEB’s combined adjudication as established above.  In this case the permanent profile listed the bilateral heel conditions, however, there was no commander’s statement and the treatment notes in the STR focused on the right foot pain and the final podiatry visit (which recommended a MEB) noted persistent X-ray changes of the right heel only.  After due deliberation, members agreed that the preponderance of the evidence did support a conclusion that the functional impairment from the right heel condition (pain) was integral to the CI’s inability to perform her MOS, but not the left heel.  Accordingly the panel cannot recommend the left heel condition as separately unfitting when considered apart from the combined adjudication.  The panel then considered its rating recommendation for the unfitting right heel condition at the time of separation.  

There was no evidence of ankle limitation of motion which attained a minimum rating under the diagnostic code for ankle motion (5271).  At the MEB NARSUM examination the CI reported continued bilateral foot pain with activity and the exam noted TTP and mild ankle swelling bilaterally, but no other abnormalities of the ankles or feet.  Therefore, Member consensus was that the evidence did not support recommending a higher rating than 0% for the right heel condition alone.  However, the bilateral stress fracture diagnoses noted on X-rays supported a single rating coded analogously to 5003 (degenerative arthritis) for “2 or more major joints” with imaging evidence of stress fractures (analogous to arthritis), without compensable limitation of motion or painful motion (as also applied by the VA); thus there is VASRD §4.71a latitude for a bilateral 10% rating.  No additional functional limitation was evidenced by the examinations.  There was therefore no VASRD §4.71a route to a higher rating under any applicable code.  The panel majority found that after unbundling the bilateral heel conditions, the highest available rating was nonetheless for the bilateral condition.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel majority recommends a disability rating of 10% for the chronic bilateral heel pain condition coded 5099-5003.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 10% for the chronic bilateral heel pain condition, coded 5099-5003.  

PANEL FINDINGS:  In the matter of the chronic bilateral heel pain condition, the panel unanimously recommends a disability rating of 10%, coded 5099-5003 IAW VASRD §4.71a.  There were no other conditions within the panel’s scope of review for consideration.  

The panel recommends that the CI’s prior determination be modified as follows, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Chronic Bilateral Heel Pain	5099-5003	10%	

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

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Dear XXXXXXXXXXXXXXXXXXXXX:

The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found that your disability rating should be modified but not to the degree that would justify changing your separation for disability with severance pay to a permanent retirement with disability.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed) and I accept its recommendation.  This will not result in any change to your separation document or the amount of severance pay.  A copy of this decision will be filed with your Physical Evaluation Board records.  I regret that the facts of the case did not provide you with the outcome you may have desired.

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.

A copy of this decision has also been provided to the Department of Veterans Affairs.

Sincerely,
Enclosure