RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01351
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20061016

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Automated Logistical Specialist, medically separated for “chronic bilateral foot pain,” with a disability rating of 10%.  

CI CONTENTION:  The CI contends that there were other conditions such as adjustment disorder that were not considered.  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 – 20060726	VARD - 20070209	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Bilateral Foot Pain	5299-5276	10%	Bilateral Pes Planus	5276	10%	20060929	
			Right Foot Subtalar Joint Coalition	5271	0%	20060929	
			Left Foot Subtalar Joint Coalition	5271	0%	20060929	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Chronic Bilateral Foot Pain.  According to service treatment records (STRs) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s chronic bilateral foot condition began in August 2005 after deployment.  The CI had moderate asymptomatic pes planus noted on her MEPS examination (DD Form 2808) dated 6 November 2002.  Weight bearing X-rays of the feet dated 5 December 2005 demonstrated severe bilateral pes planus and degenerative changes in the first metatarsophalangeal joint.  A note dated 4 April 2006 indicated the CI had suspected STJ (subtalar joint) coalition (abnormal union of two or more bones in the hindfoot and midfoot) of both feet with 10/10 pain (10 being the worst pain) with running and prolonged walking activities.  On examination the CI had minimal range of motion (ROM) of the STJs bilaterally.  There was a full ROM of both ankles, but the CI had pain in the posterior STJ area with dorsiflexion bilaterally.  There was rigid pes planus of the feet bilaterally in stance and mild rear foot (RF) valgus (fixed osseous structural abnormal where the calcaneus is inverted when the STJ is neutral and metatarsal joint is locked) bilaterally.  There was no erythema, edema, or ecchymosis of the feet.  Computerized tomography (CT) demonstrated substantial coalition of the STJ bilaterally and there were degenerative changes/adaptation of the dorsal talonavicular joints of the feet.  The examiner’s assessment was tarsal coalition (talocalcaneal) based on the coalition of the middle facet STJs bilaterally (symptomatic).  

During the April 2006 MEB examination (recorded on DD Forms 2807-1 and 2808), 6 months prior to separation, the CI reported she had pain in the feet when she ran, walked for distances, stood for long periods, got out of bed in the morning, sat for long periods then stood, and had pain all the time.  She also noted frequent swelling of the feet after running or walking long distances and used orthotic supports in her shoes for flat feet.   Physical examination revealed tenderness to palpation over the bilateral plantar fascia with full ROM of both ankles and mild valgus deformity of the feet bilaterally.  Heel to toe walking was normal.  

The 10 May 2006 MEB NARSUM examination, 5 months prior to separation, noted complaints of chronic bilateral foot pain on the heels, right greater than left, and flattening of the feet over the prior 2 to 3 years.  Treatment included Ace wraps, activity modification, stretches, custom orthotics and nonsteroidal anti-inflammatory drugs (NSAIDS).  Physical examination revealed pain with lateral calcaneal squeezes bilaterally.  Ankle joint and midtarsal joint ROMs were within normal limits without crepitus or pain.  There was no STJ ROM bilaterally.  Complete rigid pes planus deformity of the feet was present with weight bearing and non-weight bearing.  Too-many-toes sign (when looking from the back of the foot) was noted bilaterally on weight bearing examination.  Medially prominent navicular bones were noted in stance as was rear-foot valgus bilaterally.  The CI was able to perform single and double toe raises bilaterally.  Pain was noted in the calcaneal region with attempted toe raises.  Diffuse hyperkeratosis (thickening of the skin) was noted on the lateral aspects of the bilateral heels.  Radiographs revealed a decreased calcaneal inclination angle bilaterally.  Dorsal talar beaking (a superior projection of the distal aspect of the talus) was noted bilaterally and a positive C-sign (an X-ray marker of a tarsal coalition) was present bilaterally on lateral X-ray views.  CT examination revealed extensive calcaneotalar osseous coalition of the middle facets of the subtalar joints bilaterally.  

At the 29 September 2006 VA Compensation and Pension (C&P) evaluation, 2 weeks before separation, the CI reported  feet pain for 4 years, which was aching and sharp in nature at a level of 7/10.  Pain was relieved by rest and ibuprofen (NSAID) and Tylenol (acetaminophen, a pain reliever).  She received orthotic shoe inserts in April 2006 without residual after the treatment and there was no functional impairment.  On examination the feet did not reveal any signs of abnormal weight bearing.  The right and left feet revealed no tenderness, weakness, edema, atrophy or disturbed circulation.  Pes planus was present with no valgus or forefoot/midfoot malalignment present on the right.  Palpation of the right foot plantar surface revealed severe tenderness and the right Achilles tendon had good alignment.  Palpation of the left foot plantar surface revealed severe tenderness and the left Achilles tendon had good alignment.  Pes cavus was not present.  No hammer toes were found and Morton’s metatarsalgia was not present.  There was no hallux valgus or hallux rigidus and the CI did not have any limitation with standing and walking.  Weight bearing X-rays of the right and left feet showed pes planus.   The examiner’s diagnosis was bilateral pes planus based on the history of flat feet and flat feet on examination with positive X-ray findings. 

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the chronic bilateral foot pain condition 10% (based on a 10% rating minus an undetermined EPTS factor), coded 5299-5276 (flatfoot, acquired), citing congenital pes planus and subtalar joint coalition.  The VA also rated the chronic bilateral foot pain condition 10% coded 5276, based on the C&P examination 2 weeks before separation, citing the condition existed prior to military service, permanently worsened as a result of service.  No deduction was necessary since the preservice percentage was zero.  Foot pain was severe enough to prohibit the CI from fulfilling her duties.  The VA also rated the right foot subtalar joint coalition 0% coded 5271 (ankle, limited motion) and the left foot subtalar joint coalition 0% coded 5271, citing no limited motion or functional limitation on motion.  Panel members noted that rating for code 5276 provides a 10% rating for a moderate disability for either bilateral or unilateral involvement, while a severe disability warrants a 20% rating for unilateral involvement and 30% for bilateral involvement.  However, members noted there was no objective evidence of marked deformity (pronation, abduction, etc.) or characteristic callosities, but there was pain on manipulation and use accentuated and subjective reporting of swelling on use.  Therefore, panel members felt that neither the right foot nor the left foot rose to the level of a severe disability, albeit the CI had service aggravated EPTS bilateral tarsal coalitions and moderate bilateral pes planus.  Alternative rating options do not offer a route to a higher rating, although code 5283 (tarsal, or metatarsal bones, malunion of, or nonunion of) was considered, but the bilateral tarsal coalition was congenital and represents an ankylosis rather than malunion post fracture or surgery.  

After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel majority concluded that there was insufficient cause to recommend a change in the PEB adjudication for the chronic bilateral foot pain condition.  

BOARD FINDINGS:  In the matter of the bilateral foot condition and IAW VASRD §4.71a, the panel majority recommends no change in the PEB adjudication.  The single voter for dissent submitted the appended minority opinion.  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 20150615, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

Minority Opinion.  The bilateral foot pain condition represents a severe disability IAW VASRD code 5276 (Severe; objective evidence of marked deformity (pronation, abduction, etc.), pain on manipulation and use accentuated, indication of swelling on use, characteristic callosities) since there was objective evidence of a severe deformity marked by complete rigid pes planus deformity of the feet present with weight bearing and non-weight bearing, mild RF valgus bilaterally, the too many toes sign, navicular prominence, the beak sign on X-rays, and weight bearing X-rays that demonstrated severe pes planus.  Additionally, the CI had tenderness on palpation bilaterally and on use, and pain with lateral calcaneal squeezes bilaterally as well as subjective swelling.   Since the PEB determined an EPTS subtraction was undetermined, no subtraction can be determined by the minority voting panel member either.  Therefore, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the minority author recommends a disability rating of 30% for the bilateral foot pain condition, coded 5299-5276.  

Thus, the conclusion of the panel should be:

In the matter of the bilateral foot pain condition, the panel recommends a disability rating of 30%, coded 5299-5276 IAW VASRD §4.71a.  

And

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	
Bilateral Foot Pain	5299-5276	30%	

AR20170006589, 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,					       
						      					
Enclosure