RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01145
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20060518

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Wheeled Vehicle Mechanic, medically separated for “chronic left foot pain” and “chronic non-radiating low back pain,” rated 10% and 0%, respectively, with a combined disability rating of 10%.

CI CONTENTION:  His back condition continues to worsen and negatively impact quality of life.  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 - 20060310	VARD - 20061107	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Left Foot Pain	5279	10%	Status Post Left Ankle Injury	5299-5010	10%	20060606	
			Status Postoperative Left Foot Fracture	5284	10%	20060606	
Chronic Non-Radiating Low Back Pain	5237	0%	Thoracolumbar strain
	5237	20%	20060606	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Chronic Left Foot Pain.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s chronic left foot pain condition began in July 2003 after a motorcycle accident.  Injuries sustained included a complex dorsolateral (upward and outward) dislocation of the left 3rd and 4th metatarsophalangeal (MTP) joints and a left midfoot sprain with avulsion fractures of the foot (navicular, lateral cuneiform, plantar cuboid, and the anterior process of the calcaneus and the base of the 2nd metatarsal).  Surgery performed on 6 July 2003 included an open reduction of the left 3rd and 4th MTP joints.  With physical therapy pain in the foot continued to improve, although he had mild discomfort in July 2004.  However, by May 2005 the CI reported gradual onset of left foot/ankle pain over the prior 8 months, which was helped by piroxicam, a nonsteroidal anti-inflammatory drug (NSAID).  X-rays showed unremarkable osseous structures of the rearfoot. Magnetic resonance imaging (MRI) on 22 July 2005 demonstrated increased fluid uptake in the distal navicular bone at the lateral aspect.  There also appeared to be disruption of the subchondral bone of the navicular into the navicular intermediate cuneiform joint at the same location as the previous fracture.  A podiatrist noted tenderness to palpation of the posteromedial ankle and the left Achilles watershed area and prescribed heel lifts bilaterally for tenosynovitis.  Chronic left ankle pain persisted.  Soft shoes and a single point cane was prescribed in September 2005.  Evaluation in October 2005 noted that orthotics, soft shoes and a cane with no activity did help the pain, but the CI was unable to return to duty.  Physical examination revealed no gross deformity of the left foot, but there was edema and tenderness to palpation of the left sinus tarsi, and the anterior talofibular (ATF) and calcaneofibular (CF) ligaments, and the posterior tibialis tendon insertion of to the navicular.  There was also mild tenderness to palpation of the 3rd and 4th plantar metatarsal heads and pain to the distal fibular area and lateral ankle joint with motion; however, the range of motion (ROM) was within normal limits.  

During the 19 and 28 November 2005 MEB examinations (recorded on DD Forms 2807-1 and 2808), 6 months prior to separation, the CI reported arthritis in his left foot, which swelled when standing too long or walking.  The physical examiner noted a full active ROM of the left ankle/foot without deformity.  Sensation was intact to light touch.  He was tender to palpation over the ATF and CF ligaments and was neurovascularly intact and had a healed surgical scar on the dorsum of the left foot.   

The 23 January 2006 MEB NARSUM examination, 4 months prior to separation, noted complaints of increased pain with standing greater than 20 minutes or with walking greater than four blocks or a half mile.  Physical examination revealed decreased light touch sensation to the 3rd, 4th and 5th toes of the left foot.  There was tenderness to palpation of the lateral aspect of the talus anterior to the anterior malleolus and along the tibialis posterior tendon of the left foot and ankle.  He had pain with inversion and dorsiflexion against resistance on the left foot and ankle.  He was unable to perform single toe raises on the left foot.  There was pain on motion of the 3rd and 4th MTP joints of the left foot without any crepitus (grinding) and well-healed incisions were located on the dorsal aspect of the left forefoot.

At the 6 June 2006 VA Compensation and Pension (C&P) evaluation, 1 month after separation, the CI reported he suffered from arthritis and gouty arthritis marked by weakness, stiffness, swelling, redness, lack of endurance and locking of the toes.  The pain was aching, sharp, and cramping in nature and was at a level of 8/10.  On examination his feet did not reveal any signs of abnormal weight bearing and his gait was within normal limits; however, he required a cane for ambulation because of multiple foot “surgeries.”  The left ankle showed signs of tenderness and guarding of movement without any deformity.  The ROM of the left ankle was normal and was not limited by repetition. Weight bearing and non-weight bearing X-rays of the left foot were within normal limits as were X-ray findings of the left ankle.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the chronic left foot pain condition 10% rating, coded 5279 (metatarsalgia, anterior (Morton’s disease), unilateral, or bilateral), citing metatarsalgia.  The VA also rated the chronic left foot condition 10%, coded 5284 (foot injuries, other), based on the VA C&P examination 1 month after separation, citing ‘moderate’ foot symptoms.  Panel members noted that the PEB rated the CI’s disability using code 5279 for metatarsalgia; however, the CI had not only an injury and surgery to the metatarsal bones, but also avulsion fractures of several other bones of the foot as well had having tenderness of ligaments and the sinus tarsi.  While prior to surgery the CI had malalignment of metatarsal bones of the left foot, the deformities were corrected; therefore, a higher rating using code 5283 (tarsal, or metatarsal bones, malunion of, or nonunion of) is warranted although it offers no benefit to the CI.  However, the overall clinical picture of the left foot injuries (code 5284) was consistent with a moderate rating of 10% at the time of separation despite the fact the CI still used a cane to ambulate because of multiple surgeries.  Nevertheless, his gait was normal as were weight bearing and non-weight bearing X-rays.  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 chronic left foot pain condition.  

Chronic Non-Radiating Low Back Pain.  According to the STRs and the NARSUM, the CI’s low back condition began in July 2003 after a motorcycle accident, although a physical therapy note in May 2004 indicated the CI had chronic thoracic and lumbar pain since 1995, which he self-managed.  X-rays revealed mild degenerative joint disease at T7/8/9 with anterior osteophytes (arthritic changes) and end plate sclerosis (thickening).  Despite physical therapy episodes of mid thoracic pain with unsupported activity (forward bending over vehicle engine compartment and repeated lifting and carrying), pain persisted that prevented him from performing his job as a heavy wheel mechanic.  As a result he was given a P3 profile in July 2004.  Chiropractic treatment and myofascial trigger point steroid injections in early 2005 along with Percocet (oxycodone, a narcotic and acetaminophen, a pain reliever), methocarbamol (a muscle relaxer) and piroxicam provided minimal improvement of his lower to mid back pain.  An MRI in March 2005 demonstrated a small disk protrusion at T10-11 with mild facet degeneration in the lumbar spine.  Epidural steroid injections were given in September 2005 and November 2005 along with trigger point injections at the left T6-10.  Physical therapy ROM measurements in November 2005 were flexion of 41/38/38 degrees limited by pain and right side bending 20/20/20 degrees limited by pain; extension, left side bending and bilateral rotation all had full ROMs.  At a family practice visit on 22 March 2006 the CI rated his ability to perform daily activities as fair, but not enough to do the things he wanted to do, although he had 70% relief with the medications including gabapentin (for nerve pain), methocarbamol, and Percocet.  Pain limited lifting, bending, jumping, running, sit-ups, and prolonged standing and interfered with sleep and walking ability.  On examination the CI’s lower back exhibited swelling on the left side.  There was tenderness on palpation with muscle spasm.  Neurologic evaluation revealed no decreased response to tactile stimulation and motor strength was normal, but with poor conditioning.  

During the 19 and 25 November 2005 MEB examination (recorded on DD Forms 2807-1 and 2808), 6 months prior to separation, the CI reported back pain and an inability to bend and to lift.  He also noted numbness and tingling on the left side of the body the majority in the left foot to the lower back.  Physical examination showed there was tenderness to palpation over the mid thoracic spinal paravertebral left border with an increased prominence of the thoracic paravertebral muscles.  Straight leg raises (to determine nerve root irritation) were negative.  Heel-toe walking was okay with difficulty of the left foot.  There was decreased ROM in flexion and lateral rotation.  Neurologic evaluation was unremarkable.  

The 23 January 2006 NARSUM examination, 4 months prior to separation, noted complaints of the CI being unable to perform his duties as a heavy wheeled mechanic and being not likely to get any better considering the condition was long standing and he had participated in many treatment modalities.  An MRI of the thoracic and lumbar spine revealed some evidence of desiccation at multiple thoracic levels.  He had an open patent foramen (where nerves pass through the vertebral column) and no evidence of spondylosis (arthritis or degeneration of the spine) or spondylolisthesis (a vertebra sliding forward over the vertebra below it).  There was no foraminal narrowing in his thoracic or lumbar spine.  Plain radiographs showed maintenance of the disk space and disk height and very minimal evidence of subchondral changes in the thoracic spine.  He had some loss of height at multiple levels as well as what appeared to be an old minimal anterior compression fracture of the T11 vertebral body.  ROM measurements were appended from the physical therapy examination dated 28 November 2005 as noted above and are in the chart below.  

At the 6 June 2006 VA Compensation and Pension (C&P) evaluation, 1 month after separation, the CI reported constant pain that travelled to the “left hip to foot and up left side of neck”  with a severity of 8/10.  He related incapacitating episodes as often as once a month, which lasted for 6 days and over the prior year he had 15 incidents of incapacitation for a total of 60 days.  The examiner noted the functional impairment was “difficulty with bending, lifting, sleeping, driving, pushing, pulling, standing, and sitting.”  On examination the CI’s posture and gait were within normal limits, but he required a cane for ambulation because of foot surgery.   There was no evidence of radiating pain on movement.  Muscle spasm was absent and there was no tenderness or ankylosis.  A straight leg raising test was negative on the right and positive on the left.  ROM measurements are in the chart below.  X-rays dated 9 June 2006 were negative.  

The ROM examinations in evidence which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below.  

Thoracolumbar ROM
(Degrees)	PT / MEB ~6 Mos. Pre-Sep
	VA ~1 Mos. Post-Sep
	
Flexion (90 Normal)	(40)41, 38, 38* 	60	
Extension (30)	Full ROM	20	
R Lat Flex (30)	(20), 20, 20, 20*	20	
L Lat Flex (30)	Full ROM	20	
R Rotation (30)	Full ROM	30	
L Rotation (30)	Full ROM	30	
Combined (240)		180	
Comments	

Pain limit	Pain occurred at the end of flexion, extension and lateral flexion bilaterally; joint function limited by 0 degrees with repetition; cane used	
§4.71a Rating	20% (PEB 10%)	VA 20%	

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the low back pain condition 0%, coded 5237 (lumbosacral strain), citing limitation of motion due to pain.  The VA rated the low back pain condition 10%, coded 5237, based on the VA C&P examination 1 month after separation, citing limitation of forward flexion.  The panel agreed that a 20% rating, but no higher, was justified for limitation of flexion (greater than 30 degrees but not greater than 60 degrees) reported on the NARSUM and VA examinations.  The panel considered whether a higher rating (§4.7) was achieved by using the alternate rating formula based on incapacitating episodes due to intervertebral disc syndrome (IVDS).  The evidence showed the CI had some features of IVDS (disc disease causing back pain) and he reported at the VA C&P examination having experienced incapacitating episodes; however, there was no evidence in the STRs or based upon the VA examination that bed rest was prescribed by a physician.   Therefore, Board members did not consider a rating under the alternate VASRD formula (for IVDS) was warranted.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 20% for the chronic non-radiating low back pain condition, coded 5237.  

BOARD FINDINGS:  In the matter of the chronic left foot pain condition and IAW VASRD §4.71a, the panel majority recommends no change in the PEB adjudication.  The single voter for dissent recommends modification to 20% and did not elect to submit a minority opinion.  In the matter of the chronic non-radiating low back pain condition, the panel unanimously recommends a disability rating of 20%, coded 5237 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; 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	
Chronic Left Foot Pain	5279	10%	
Chronic Non-Radiating Low Back Pain	5237	20%	
COMBINED	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150612, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170007446, XXXXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXXXX:

	I accept the recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) to re-characterize your separation as a disability retirement with the combined disability rating of 30% effective the date of your medical separation for disability with severance pay.  Enclosed is a copy of the Board’s recommendation and record of proceedings for your information.

	The re-characterization of your separation as a disability retirement will result in an adjustment to your pay providing retirement pay from the date of your original medical separation minus the amount of severance pay you were previously paid at separation.
 
	The accepted DoD PDBR recommendation has been forwarded to the Army Physical Disability Agency for required correction of records and then to the U.S. Defense Finance and Accounting Service to make the necessary adjustment to your pay and allowances.  These agencies will provide you with official notification by mail as soon as the directed corrections have been made and will provide information on your retirement benefits.  Due to the large number of cases in process, please be advised that it may be several months before you receive notification that the corrections are completed and pay adjusted.  Inquiry concerning your correction of records should be addressed to the XXXXXXXXXXXXXXXXXXXXX.

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

Sincerely,					      
Enclosure