RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-02349
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20070820

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an Reserve E4, Generator Mechanic, medically separated for “chronic pain of the right tibia and left foot…” with a disability rating of 0%.

CI CONTENTION:  “Over 12 fractures in my left foot, which was left untreated by the Army for nearly a month or so.  My right leg according to the doctor was 2 weeks away from breaking at the shin.  I still have issues today from improper healing.”  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 - 20070606	VARD - NA	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Pain of the Right Tibia and Left Foot	5099-5003	0%	No VA Exam in Evidence	
COMBINED RATING:  #%	COMBINED RATING OF ALL VA CONDITIONS:  NA	

ANALYSIS SUMMARY:  

Chronic Pain of the Right Tibia and Left Foot.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI first presented with numbness in her feet for the previous 3 weeks.  On examination she had diffuse tenderness over the mid feet and was placed on limited duty.  X-rays were normal.  Her pain improved, but persisted.  A bone scan on 1 August 2002 showed stress fractures of the left 2nd metatarsal (long bone in the foot), both shins, and the left femur near the knee.  She was seen that day in orthopedics and noted to have swelling of the left foot and missing nails of the 4th and 5th toes on the left.  She was tender over both shins and the left foot.  She was given a walker for partial weight bearing and continued on limited duty.  Over the following weeks, she noted some improvement in her symptoms.  In orthopedics on 19 September 2002, she reported resolution of the right leg pain, but persistent left foot and knee pain.  She reported a recent slip and fall onto the left leg.  X-rays were noted to show neither a fracture of dislocation of the left knee.  She was then seen 4 days later and reported that she was improved and walking without crutches.  Her examination was normal other than mild tenderness to palpation over the femur and foot.  No sensory abnormalities were documented.  There are no further records in evidence until the CI was entered into the MEB system.  The CI was apparently considered for separation in 2004, but this action was not completed.  

The MEB examination (recorded on DD Forms 2807 and 2808) was performed on 22 March 2007 5 months prior to separation.  The CI reported pain in her left foot, left knee, and right shin.  She also noted that her left knee would lock periodically.  On physical examination, she was tender to palpation over the right shin and the top (dorsum) of the left foot.  The MEB NARSUM was prepared the next day, 23 March 2007, by orthopedics.  It noted that she had completed her course work in advanced individual training, but had not graduated as she could not take the physical fitness test.  She was then released from active duty and had been drilling with her unit.  She did office work for her unit and also worked as a receptionist in her civilian job.  She reported that her left knee would catch every now and then.  Her major concern was her left foot though.  Weight bearing increased her pain and she could not run.  On examination, her gait was normal.  The knees were normal and signs of instability or meniscal (internal cartilage cushions) were absent.  Atrophy was absent.  The range of motion (ROM) was full and painful motion was not documented.  The right shin was tender to touch, but without swelling.  Alignment was normal.  The ankles were stable and non-tender.  The ROM showed that the left ankle had 5 degrees less dorsiflexion (toes up) than the right and 10 degrees less plantar flexion (toes down).  Both feet were had less dorsiflexion than VA normal values (by 10 degrees and 5), respectively, and exceeded VA normal values for plantar flexion (by 5 and 15 degrees, respectively).  The limitation was due to pain.  Her feet were supple and had normal alignment.  The left metatarsal was tender at the joint with the toe (MTPJ).  She was thought to have chronic stress reactions of the right tibia (shin) and left foot.  There was no VA examination in evidence proximate to separation.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the right tibia and left foot pain at 0%, coded 5099-5003 (analogous to degenerative arthritis), citing the US Army Physical Disability Agency pain policy.  The panel first considered if the right tibia and left foot pain were separately unfitting.  Both had been noted to have stress fractures during the initial evaluations in 2002.  The evidence did show that the right shin pain resolved even though left leg pain persisted (after a fall).  No imaging studies proximate to separation were in evidence.  Her gait was normal as was the ROM of the knees.  Both the right shin and left forefoot were tender to palpation, but there was no other indication of pathology.  Her major complaint was of left foot pain.  The evidence supports a finding that the left foot condition was separately unfitting, but is less conclusive regarding the right shin.  There were no imaging studies in evidence more recent than those done at the onset of her symptoms, 5 years prior to separation.  However, both were noted by the examining orthopedic surgeon, both cited on the MEB as medically unacceptable, and both were included on the profile.  The PEB determined that the unfitting condition was the chronic pain due to both the right tibia and left foot.  Accordingly, the panel recommended that each condition be considered to be separately unfitting and rated separately.  

The left forefoot was tender to palpation.  The gait was normal though as was the alignment.  The code 5279, metatarsalgia, supported a 10% rating for the chronic pain aggravated by activity.  The right shin was also tender, but the CI reported that it was less problematic than the left foot.  Again, the gait was normal.  The ROM of the knee was normal and that of the ankle exceeded the left side.  Review of the imaging studies from 2002 does not show that either ankle was involved in her impairment.  The code 5262 (impairment of the tibia and fibula) supported a 0% rating.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 0% for the right shin condition, coded 5262, and 10% for the left foot condition, coded 5279.  

BOARD FINDINGS:  In the matter of the right tibia condition, the panel unanimously recommends a disability rating of 0%, coded 5262 IAW VASRD §4.71a.  In the matter of the left foot condition, the panel unanimously recommends a disability rating of 10%, coded 5279 IAW VASRD §4.71a.  There are 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 Tibia Pain	5262	0%	
Left Foot Pain	5279	10%	
COMBINED	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150602, w/atchs
Exhibit B.  Service Treatment Record

AR20170012864, 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