RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01989
BRANCH OF SERVICE:  navy 	SEPARATION DATE:  20050315

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E2, Electrical/Mechanical Equipment Repairman, medically separated for “stress fractures of tarsal bones bilateral and calcaneus on left” with a disability rating of 10%.  

CI CONTENTION:  “Review all conditions.”  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 - 29959131	VARD – 20051006	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Stress Fractures of Tarsal Bones Bilateral and Calcaneus on Left	5022-5003	10% 	Left Foot Metatarsal and Os Calsis Stress Fracture  	5283-5273	0%	20050124	
			Right Foot Metatarsal Stress Fracture	5283	0%	20050124	
Cavus Feet	Category III	 No VA Placement	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY:  

Bilateral Stress Fractures of Tarsal Bones and Calcaneus on Left.  The PEB combined the stress fractures of the feet into a single unfitting condition coded 5022-5003.  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 panel also noted that “bundling,” the combining of two or more major joints, may be permissible under the VASRD 5003 (and 5022) rating requirements, and that this approach does not compromise the VASRD §4.7 directive to choose the higher of two valid ratings.  The panel’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 panel 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 DES or be found unfit because of physical disability.  When the panel recommends separate fitness recommendations in this circumstance, its recommendations may not produce a lower combined rating than that of the PEB.  The evidence for these conditions is presented together, with attendant recommendations regarding separate unfitness, and separate rating if indicated.  

According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI initially presented with bilateral heel blisters attributed to tight boots in September 2004.  These were treated, but his pain persisted.  He was referred to podiatry where he was noted to have bilateral high arches.  X-rays were unremarkable otherwise.  A nuclear bone scan performed on 8 November 2004 was consistent with stress fractures of the tarsal bones bilaterally as well as the left calcaneus (heel bone).  He was issued shoe inserts and placed on light duty, but his symptoms persisted and he was not able to resume training.  

At the 30 November 2004 MEB NARSUM examination, 3 months prior to separation, the CI reported continued pain in both feet.  On examination, both heels were tender and motion was limited, primarily dorsiflexion.  It was thought that the fractures were healing.  

At the 24 June 2005 VA Compensation and Pension (C&P) evaluation, 3 months after separation, the CI reported left greater than right foot pain as well as left heel pain.  He stated that his feet had improved from when he was in the Navy.  He reported that he could mow the lawn for 45 minutes before a rest period and then finish the lawn after another 45 minutes.  He used medications before mowing, but did not use medications on a regular basis.  The examiner found the CI had full painless range of motion of the hips, knees and ankles.  The CI's gait was noticeable for a minimal degree of limp on the left.  He had normal associated arm swing.  He had no problems getting up and out of the examination chair and walking down the hall to x-ray, other than the observed gait pattern.  A heel walk was difficult on the left; he was able to toe walk bilaterally.  X-rays were normal.  The feet were tender to manipulation.  The arches were noted to be normal.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral foot stress fractures 10%, coded 5022-5003 (periostitis—degenerative arthritis).  The VA rated the left foot stress fractures 0%, coded 5283-5273 (malunion or nonunion of tarsal or metatarsal bones--malunion of os calcis or astragalus), based on the C&P examination 2 months before separation, citing no current evidence of stress fractures or malunion of prior fractures by x-ray and only mild symptoms of foot pain without significant functional limitation due to weakness, fatigue, lack of endurance or incoordination.  The VA rated the right foot stress fracture 0%, coded 5283 (malunion or nonunion of the tarsal or metatarsal bones), based on the C&P examination 2 months before separation, citing no current evidence of stress fractures or malunion of prior fractures by x-ray and only mild symptoms of foot pain without significant functional limitation due to weakness, fatigue, lack of endurance or incoordination.  

The panel first considered if the bilateral foot stress fractures were separately unfitting.  The bone scan showed stress fractures for all and the MEB cited all as medically unacceptable.  The evidence supported a finding that each was separately unfitting.  The panel then considered the evidence.  The MEB NARSUM noted that the conditions were resolving and the VA C&P examination showed that healing was nearly complete.  There was minimal tenderness, but normal X-rays and range of motion at the VA examination.  There was a slight limp, but the CI was able to mow a lawn for 45 minutes before taking a break.  The evidence only supports 0% ratings for each foot.  Therefore, separate unfitness determinations accord no advantage to the CI.  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 stress fractures of the bilateral tarsal bones and left calcaneus.  

Contended PEB Condition:  Cavus Feet.  The panel’s main charge is to assess the fairness of the PEB’s determination that the contended condition was Category III (conditions that are not separately unfitting and do not contribute to the unfitting condition).  The contended condition was not implicated in the Non-Medical Assessment.  There was no performance-based evidence from the record that the condition significantly interfered with satisfactory duty performance at separation.  The arches were thought to be normal on the VA examination.  After due deliberation, the panel 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 stress fractures of the bilateral tarsal bones and left calcaneus condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  In the matter of the contended cavus feet condition, the panel unanimously recommends no change from the PEB determination as category III.  There are 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 20150713, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record 

MEMORANDUM FOR DIRECTOR, SECRETARY OF THE NAVY COUNCIL OF REVIEW
               BOARDS 

Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS
 
Ref:   (a) DoDI 6040.44

      In accordance with reference (a), I have reviewed the cases listed below and approve the recommendations of the PDBR that the following individual’s records not be corrected to reflect a change in either characterization of separation or in the disability rating previously assigned by the Department of the Navy’s Physical Evaluation Board:

		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USN

		
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	     				  Acting