RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01665
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20020531

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an Reserve O2, Tactical Intelligence, medically separated for “pain post left tarsal tunnel…” 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 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.  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 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 - 20020301	VARD - 20021213	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Pain Post Left Tarsal Tunnel…Right Tarsal Tunnel Syndrome	5099-5003	10%	Residuals, Right Tarsal Tunnel Syndrome	8699-8625	10%	20021015	
			Residuals, Left Tarsal Tunnel Syndrome		10%		
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Bilateral Tarsal Tunnel Pain.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s bilateral foot pain condition began without specific injury or trauma.  Initially, only the left foot was involved and electro-diagnostic studies revealed a definitive tarsal tunnel syndrome involving the lateral plantar nerve. She underwent nerve release surgery on 1 March 2001.  Post-operative repeat electro-diagnostic studies revealed no further abnormality of the left lateral plantar nerve.  Despite surgery and physical therapy (PT) rehabilitation, the CI continued to have left foot pain.  Eventually, she developed similar symptoms in the right foot and was diagnosed with bilateral tarsal tunnel syndrome on 06 September 2001.  
During the 10 January 2002 MEB examination (recorded on DD Forms 2807 and 2808), 5 months prior to separation, the CI reported the inability to run, ruck march, or wear military boots for greater than a few hours due to bilateral foot pain.  Her physical examination (PE) revealed “subjective decreased sensation in both feet along the medial and posterior aspect of ankle and medial plantar aspect of mid-foot.”  Metatarsal tenderness was present; left greater than right foot.  At the MEB NARSUM examination on 25 January 2002, 4 months prior to separation, the CI reported no additional physical complaints.  Her PE revealed bilateral ankle edema with right-sided painful motion.  There was altered sensation along both distal posterior tibial nerves and a tinel’s sign was bilaterally positive, indicative of the final diagnosis.  The CI was placed on an L4 profile and the commander’s statement noted, “…the [CI] can only wear the standard issue combat boot for a couple hours at a time before she begins to experience unbearable pain in both legs.”  At the 15 October 2002 VA Compensation and Pension (C&P) evaluation, performed 5 months after separation, the CI reported no additional physical complaints.  Her VA PE was limited in scope and did not note specific abnormalities within either foot.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB bundled the right and left foot conditions under a single disability rating, analogously coded 5003 (degenerative arthritis) and rated 10% citing the presence of pain.  The VA separately rated each foot at 10% under the analogous code 8699-8625 (neuritis of the posterior tibial nerve) citing incomplete paralysis of foot movements.  The panel’s initial charge in this case was directed at determining if the PEB’s approach of combining the bilateral foot condition as a single rating was justified in lieu of separate ratings.  The panel must apply separate codes and ratings in its recommendations if compensable ratings for each extremity condition are achieved IAW VASRD §4.71a.  If the panel judges that two or more separate ratings are warranted in such cases, however, it must satisfy the requirement that each ‘unbundled’ condition was unfitting in and of itself.  Panel members agreed that the CI’s inability to wear military combat boots for no greater than a couple of hours would indeed support an unfitting condition if either foot was independently affected.  Therefore, the panel recommends that each foot condition was separately unfitting and ratable.  

Panel members placed little probative value on the VA evaluation due to its limited physical examination and therefore, a rating recommendation will be heavily based upon pre-separation clinical encounters such as the MEB.  Members agreed that the persistence of altered sensation and corresponding posterior tibial nerve irritation findings such as a positive tinel sign would easily be supported under the VASRD nerve code of 8625 (neuritis).  The ratings involved under this code is 10% for either mild or moderate impairment and 20% for severe impairment.  All members further agreed that the degree of impairment did not support a severe 20% level and therefore, after due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends separate disability ratings of 10% for each foot. 

BOARD FINDINGS:  In the matter of the bilateral foot pain condition, the  panel unanimously recommends separate disability ratings of 10% each foot coded 8625 IAW VASRD §4.124a.  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	
Right Tarsal Tunnel Pain Syndrome	8625	10%	
Left Tarsal Tunnel Pain Syndrome	8625	10%	
COMBINED 	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150626, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170008832, XXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXX:

	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