RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01304
BRANCH OF SERVICE:  Navy 	SEPARATION DATE:  20040120

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E1, Seaman Recruit, medically separated for “bilateral fourth metatarsal stress fractures,” with a disability rating of 10%.

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 panel 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 - 20040105	VARD - 20040221	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral 4th Metatarsal Stress Fractures	5003-5283	10%	Stress Fracture of the Right 4th Metatarsal	5299-5284	NSC	STR	
			Stress Fracture of the Left 4th Metatarsal	5299-5284	NSC		
Left 3rd Metatarsal Stress Fracture	Cat II	Stress Fracture of the Left 3rd Metatarsal	5299-5284	NSC		
Left Tibial Diaphysis Stress Fracture	Cat III	Left Tibial Stress Fracture	5299-5262	NSC		
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  NSC	

ANALYSIS SUMMARY:  

Bilateral Fourth Metatarsal Stress Fractures.  According to service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s bilateral foot condition began in August 2003 during a physical training exercise in boot camp.  Despite treatment, the bilateral foot condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and the CI was referred for an MEB.  The MEB forwarded “bilateral fourth metatarsal stress fracture and left third metatarsal stress fracture” for PEB adjudication.  

The MEB NARSUM on 5 November 2003, 3 months before separation, the CI reported complaints of being unable to run for greater than 1/4 mile or walk or stand for a prolonged period of time without leg and foot pain.  Physical examination showed:  Gait: Intact heel, toe and tandem gait. Both hips demonstrated full range of motion (ROM) and bursitis testing was negative.  There was no evidence of edema or ecchymosis.  Both knee demonstrated ROM flexion of 130 degrees (140 normal).  There was no evidence of an effusion and instability or knee tenderness to palpation.  Meniscal tests were negative.  The femurs were non-tender to palpation at medial femoral condyle, lateral femoral condyle.  There was left tibial shaft tenderness to palpation.  The ankles demonstrated: ROM: plantar flexion (PF) 40 degrees, dorsiflexion (DF) 20 degrees.  There was no ankle tenderness to palpation.  There was no ankle instability.  There was tenderness to palpation at third and fourth metatarsal shafts.  The neuromuscular examination was normal.  Radiographic imaging confirmed a healing right fourth metatarsal fracture, a healing left third and fourth metatarsal fractures, and a left mid-tibia stress fracture.  

There was no VA Compensation and Pension (C&P) examination in evidence, the CI failed to report to a scheduled examination on 18 December 2003.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral foot condition 10%, coded 5003-5283 (degenerative arthritis – malunion or non-union of tarsal or metatarsal bones).  The VA did not service connect the bilateral fourth metatarsal stress fracture condition, coded 5299-5284 (analogous to other foot injuries).  The PEB combined the left third and fourth metatarsal stress fractures and right 4th metatarsal stress fracture conditions as a single unfitting condition coded analogously to 5003-5283 and rated 10%.  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 Board 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 Board’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 Board 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 Disability Evaluation System or be found unfit because of physical disability.  When the Board 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 left third and fourth metatarsal stress fractures and right fourth metatarsal stress fracture conditions are presented separately, with attendant recommendations regarding separate unfitness, and separate rating if indicated.  

The Board first considered if the bilateral fourth metatarsal stress fractures, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  In this case, both feet were considered to fail retention standards and implicated by the NARSUM and in the commander’s statement.  Board members agreed that the evidence reasonably justified that the functional limitations of each foot contributed to the CI’s inability to perform his military duties and accordingly a separate disability rating is recommended.  There was evidence of ongoing stress fractures with pain that supported a rating under the VASRD diagnostic codes for malunion of, or nonunion of the metatarsal bones (5283) for each foot.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board determined that each foot was unfitting and recommends disability ratings of 10% for the left fourth metatarsal stress fracture condition, 5283 and 10% for the right fourth metatarsal stress fracture condition, 5283.  The PEB listed the left third metatarsal stress fracture condition as a related diagnosis (Category II) that contributed to the disability in this case.  The Board agreed the left third metatarsal stress fracture was a diagnosis related to the right fourth metatarsal stress fracture and was not a separate condition which could be separately rated IAW §4.14 (avoidance of pyramiding; more than one rating based on the same impairment is prohibited).  

Contended PEB Condition:  Left Tibial Diaphysis Stress Fracture.  The Board’s main charge is to assess the fairness of the PEB’s determination that the contended condition was not unfitting.  The contended condition was not profiled or implicated in the commander’s statement or judged to fail retention standards.  There was no performance-based evidence from the record that the condition significantly interfered with satisfactory duty performance at separation.  After due deliberation, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the contended condition and so no additional disability rating is recommended.  

BOARD FINDINGS:  In the matter of the bilateral fourth metatarsal stress fracture conditions, the Board unanimously determined that each foot was unfitting and recommends disability ratings of 10% for the left fourth metatarsal stress fracture condition, coded 5283 and 10% for the right fourth metatarsal stress fracture condition, coded 5283 IAW VASRD §4.71a.  In the matter of the contended left third metatarsal stress fracture condition, the Board unanimously recommends no change from the PEB determinations as a related Category II diagnosis.  In the matter of the contended left tibial diaphysis stress fracture condition, the Board unanimously recommends no change in the PEB adjudication as not unfitting.  There were no other conditions within the Board’s scope of review for consideration.  The Board 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	
Right Fourth Metatarsal Stress Fracture	5283	10%	
Left Fourth Metatarsal Stress Fracture	5283	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150615, w/attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

	 

MEMORANDUM FOR DEPUTY COMMANDANT (Manpower and Reserve Affairs)
		   COMMANDER, NAVY PERSONNEL COMMAND	
	                          
Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS          

Ref:  (a) DoDI 6040.44
	(b) PDBR ltr dtd 17 Jan 17 ICO XXXXXXXXXXXXXXXXXX
	(c) PDBR ltr dtd 17 Dec 17 ICO XXXXXXXXXXXXXXXXXX   
	(d) PDBR ltr dtd 20 Sep 17 ICO XXXXXXXXXXXXXXXXXX
	(e) PDBR ltr dtd 27 Oct 17 ICO XXXXXXXXXXXXXXXXXX 
	(f) PDBR ltr dtd 31 Jul 17 ICO XXXXXXXXXXXXXXXXXX
	(g) PDBR ltr dtd 07 Dec 17 ICO XXXXXXXXXXXXXXXXXX

1.  Pursuant to reference (a), the recommendations of the Physical Disability Board of Review set forth in references (b) through (g) are approved.  The official records of the following individuals are to be corrected as follows:

     a. XXXXXXXXXXXXXXXXXX, former USN: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge. 

     b. XXXXXXXXXXXXXXXXXX, former USMC: Placement on the Permanent Disability Retired List with a 30 percent rating (increased from 10 percent) effective date of discharge.

     c. XXXXXXXXXXXXXXXXXX, former USN: Entitlement to disability separation pay with a 10 percent disability rating (increased from 0 percent) effective date of discharge.      

     d. XXXXXXXXXXXXXXXXXX, former USMC: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge. 

     e. XXXXXXXXXXXXXXXXXX, former USN: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge. 

     f. XXXXXXXXXXXXXXXXXX, former USMC: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge. 
     
2.  Please take action to implement these decisions and provide notification to the above individuals once those actions are complete.