RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-02129
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20050330

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E1, Basic Trainee, medically separated “bilateral foot pain due to Achilles tendonitis with left calcaneal stress changes” with a disability rating of 0%.

CI CONTENTION:  “VA did not service connect foot 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 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 - 20050317	VARD - 20070523	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Foot Pain…	5024	0%	Left Calcaneal Stress Fracture (Claimed as Bilateral Stress Fractures Metatarsal Bones)	5284	NSC	20070510	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  NSC	

ANALYSIS SUMMARY:

Bilateral Feet (Achilles Tendonitis with Left Calcaneal Stress).  The PEB combined the bilateral foot pain due to Achilles tendonitis with left calcaneal stress changes conditions as a single unfitting condition coded 5024 (Tenosynovitis) and rated 0% with application of the US Army Physical Disability Agency (USAPDA) pain policy and AR 635-40 B24.f.  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’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 the bilateral foot pain due to Achilles tendonitis with left calcaneal stress changes conditions are presented with attendant recommendations regarding separate unfitness, and separate rating if indicated.  

According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s bilateral foot condition began in November 2004 after her second week of basic training.  Radiographic imaging (X-ray) for bilateral heels revealed a left calcaneal stress fracture.  Conservative treatment did not result in improvement sufficient to allow unrestricted duty.  At the physical therapy examination dated 17 February 2005, 1 month prior to separation, the CI reported bilateral heal and ankle pain rating her pain as 4/10 at rest and 7-8/10 with movement.  Physical examination showed the CI’s gait and stance were normal.  Bilateral ankle motion was normal.  Negative anterior drawer sign in the ankles.  Negative talar tilt test.  No tenderness was observed on ambulation in the ankles.  No weakness of the ankles.  Feet showed tenderness on palpation of both heels, L>R.  There was no swelling of the feet, no excessive pronation of the feet, no excessive supination of the feet and no pain was elicited by motion of the foot.  Gait and Stance were normal.  Standing posture was normal.  Functional examination showed that the CI’s mobility was not limited and she was able to perform a full squat and single leg stance without pain.  Her ambulation was not limited.  An X-ray on 16 February 2005 revealed a left calcaneous (heel) stress fracture.  

During 25 February 2005 MEB examination (recorded on DD Forms 2807-1 and 2808), 1 month prior to separation, the CI reported a history of feet and ankle pain.  Physical examination showed bilateral medial and lateral pain with heel squeeze, pain on bilateral Achilles.  No edema and normal ankle range of motion.  The MEB NARSUM examination on 28 February 2005, 1 month prior to separation, noted complaints of "My feet feel swollen and throbbing".  Her pain averages 2-3/10 and up to 7-8/10 when marching or standing for prolonged periods of time, right more than left despite the stress fracture being on the left.  Physical examination showed a normal tandem, non-antalgic gait.  Her bilateral feet and ankles had positive medial and lateral heel squeeze, right more than left and also had bilateral Achilles tendon tenderness.  There was no swelling, ecchymosis or edema.  She had full, normal range of motion of her bilateral ankles.  She was neurovascularly intact with normal pulses.  The VA Compensation and Pension (C&P) examination dated 10 May 2007 was performed over 25 months after separation.  Because of the remoteness of this examination it offers little to no probative value.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral foot pain 0%, coded 5024 (tenosynovitis), citing no foot or ankle limitation of motion.  The VA did not service-connect the bilateral foot condition, coded the left ankle 5284 (foot, other injury), based on the C&P examination over 2 years after separation, citing a normal heel examination with 16 February 2005 X-ray evidence of left calcaneal stress fracture.  The panel first considered if the each foot, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  Both feet were profiled and limitations included no running, jumping, or marching.  Panel members agreed that the evidence reasonably justified that the functional limitations of each foot contributed to the CI’s inability to perform her military duties and accordingly separate disability ratings are recommended.  

Left Foot:  All panel members agreed the left foot pain due to Achilles tendonitis with left calcaneal stress changes was no more than mild, therefore supporting the 0% rating adjudicated by the PEB 5024 (tenosynovitis).  The left injury was less than moderate, to support a 10% rating coded 5284 (Foot injuries, other).  There was no ankle limitation of motion to support a 10% rating (5271).  Panel members also agreed that the Achilles tendonitis, left calcaneal stress fracture were diagnoses related to the foot pain and were not separate conditions which could be separately rated IAW §4.14 (avoidance of pyramiding; more than one rating based on the same impairment is prohibited).  There was no ankle ankylosis to support a rating coded 5270.  The panel considered alternative VASRD ankle and analogous codes, but all were less applicable and not advantageous to rating.  There was no evidence of painful motion with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45) for the left foot.  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 bilateral foot pain due to Achilles tendonitis with left calcaneal stress changes conditions.  

Right Foot:  All panel members agreed the right foot pain due to Achilles tendonitis was no more than mild, therefore supporting the 0% rating adjudicated by the PEB 5024 (tenosynovitis).  The right foot injury was less than moderate, to support a 10% rating coded 5284 (Foot injuries, other).  There was no ankle limitation of motion to support a 10% rating (5271).  panel members also agreed that the Achilles tendonitis was a diagnosis related to the foot pain 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).  There was no ankle ankylosis to support a rating coded 5270.  The panel considered alternative VASRD ankle and analogous codes, but all were less applicable and not advantageous to rating.  There was no evidence of painful motion with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45) for the right foot.  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 bilateral foot pain due to Achilles tendonitis with left calcaneal stress changes conditions.  

BOARD FINDINGS:  In the matter of the bilateral foot pain due to Achilles tendonitis with left calcaneal stress change conditions and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  There were no other conditions within the panel’s scope of review for consideration.  The panel, therefore, recommends that there be no re-characterization of the CI’s disability and separation determination.  

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150726, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170010043, XXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXX

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,