RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01104
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20070705

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Food Service Specialist, medically separated for “injury to left foot…,” with a disability rating of 10%.

CI CONTENTION:  “Ongoing issues with left foot.”  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 - 20070410	VARD - 20070801	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Injury to Left Foot…	5284	10%	Residuals of Comminuted Medial and Lateral Cuneiform and Cuboid Fractures 	5299-5284	10%	20070523	
			Residual Surgical Scarring to the Left Foot	7804	10%	20070523	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Injury to Left Foot.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI injured her left foot in July 2005 while jumping on a trampoline.  Initial imaging studies were negative but persistent pain led to further evaluation, which discovered fractures of midfoot tarsal and metatarsal bones.  She required surgical open reduction and internal fixation in August 2005 for a Lisfranc injury (tarso-metatarsal fracture-dislocation).  Because of ongoing pain post-operatively, the surgical hardware was removed on 15 August 2006.

At the MEB examination (recorded on DD Forms 2807 and 2808) dated 1 March 2007, 4 months prior to separation, the CI reported left foot pain since her surgery.  Physical examination showed three well-healed left foot surgical scars.  There was soft tissue deformity and “significant hypersensitivity” over the first and second metatarsals.  The arch of the foot was considered to be “normal” and ankle range of motion was noted to be full.  The MEB NARSUM examination on 9 March 2007 (4 months prior to separation) noted complaints of hypersensitivity of the dorsomedial aspect of the left foot that worsened with application of any pressure, or with prolonged standing or walking.

At the 23 May 2007 VA Compensation and Pension (C&P) evaluation, performed a month before separation, the CI reported pain that occurred 8-9 times per day and lasted 4-5 hours.  The pain could be spontaneous or could be elicited by physical activity.  She could “walk for a long period of time but can’t stand for a long period.”  The CI could successfully accomplish daily activities that included cooking, walking, climbing stairs, shopping, vacuuming, gardening and taking out the trash, but she could not push a lawn mower.  Recreational activities included shopping and fishing.  Physical examination showed a normal gait without use of assistive devices.  There was no plantar tenderness and a normal arch was present.  There was hypersensitivity over a circular area at the top and medial aspect of the left foot.  Inversion and eversion of the foot were reduced to half of normal.  With the right foot off the ground, she could not stand on the left foot due to pain and instability of the left foot and ankle.  Left ankle dorsiflexion was 10 degrees (normal 20) and plantarflexion was 30 degrees (normal 45).  Flexion and extension of the toes did not cause pain, and there was no evidence of hammertoes, claw feet or metatarsalgia.  Left foot X-rays showed post-surgical changes.  The examiner stated that the condition did not affect functioning in her usual occupation.  At a VA clinic evaluation on 28 April 2008 (10 months after separation) the CI reported being employed as a caretaker and complained of chronic left foot pain.  Examination showed a normal gait.  Lower extremity muscle strength was normal, and there was no swelling.  Some tenderness of the left ankle was present. 

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left foot condition 10%, coded 5284 (foot injuries, other), citing “moderate” injury as the rationale.  The VA rated the left foot condition 10% coded 5299-5284 (analogous to foot injury), based on the VA C&P examination a month before separation, citing “moderate symptoms” as a rationale.  The VA also rated the left foot surgical scar 10% coded 7804 (unstable or painful scar), citing “hypersensitivity to the area affected by the scars.”  The panel considered a rating higher than the PEB’s 10%.  Under the 5283 (tarsal bone malunion) or the 5284 codes a 20% rating requires a “moderately severe” condition.  However, this level of severity could not be reconciled with the evidence at hand, and therefore a 20% rating was not justified via these coding pathways.  Under the 5271 code (ankle, limited motion of) it was agreed that the next higher 20% rating was not indicated in the absence of marked limitation of ankle range of motion.  The remaining foot codes were clinically inapplicable.  The panel does not recommend separation rating for scars unless their presence imposes a direct limitation on fitness.  The panel reviewed the STR and did not find evidence that a tender or painful scar separately interfered with duty and therefore a separate rating was not recommended.  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 left foot condition.

BOARD FINDINGS:  In the matter of the left foot condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  There were no other conditions within the panel’s scope of review for consideration.  The panel, 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 20150609, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170010607, XXXXXXXXXXXXXXXXXX

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. 

A copy of this decision has been provided to the counsel you listed on your application XXXXXXXXXXXXXXXXXX