RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXX		CASE: PD-2015-02476 BRANCH OF SERVICE: ARMY	SEPARATION DATE: 20030525

SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E2, Multichannel Transmission System Operator Maintainer, medically separated for “bilateral foot pain” 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 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 - 20030422		VARD - 20040130	
Condition	Code	Rating		Condition	Code	Rating	Exam	
Bilateral Foot Pain	5099-5003	10%		Bilateral Metatarsalgia	5299-5279	10%	20031211	
COMBINED RATING: 10%		COMBINED RATING OF ALL VA CONDITIONS: 10%	

ANALYSIS SUMMARY:

Bilateral Foot Pain. The PEB combined the bilateral foot pain conditions as a single unfitting condition coded 5099-5003 for slight/constant disability and rated 10%. The approach by the PEB commonly reflected its judgment that the constellation of conditions was unfitting, and there was no need for separate fitness adjudications or implied adjudication that each condition was separately unfitting. The panel’s initial charge in this case was 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 conditions is presented together.

According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s bilateral foot condition began in 2002 while going through basic training with any trauma or injury. The CI complained of right foot pain for 3 days at which time there was tenderness of the distal first and second metatarsals with minimal swelling. Treatment consisted of profiles, nonsteroidal anti-inflammatory drugs (NSAID), elevation and ice.   On 7 October 2002 X-rays of the left foot were normal and an X-ray series of the right ankle demonstrated a small calcified density near the lateral malleolus (outer ankle), which represented an old ligamentous calcification versus a small avulsion fracture. On 16 October 2002, he complained of persistent right foot and ankle pain with a benign evaluation. At an orthopedic evaluation the CI still had right forefoot pain, but the ankle pain had improved. On examination his ankle was stable and non-tender with a full range of motion (ROM), while the right foot was tender to palpation at the third to fifth metatarsals with a normal arch. The diagnosis of right foot metatarsalgia was made and treatment consisted of Spenco [inserts] with a metatarsal bar. X-rays of the right foot were normal on 5 November 2002. The CI reported no significant relief and increasing pain on the left side at an orthopedic visit on 10 December 2002. On examination he had neutral heels and normal arches with a full ROM of the ankles and subtalar joints. There was mild tenderness to palpation at the plantar second to fifth metatarsals, but no calluses. Bilateral tight Achilles tendons were present bilaterally. Physical therapy was suggested for Achilles tendon stretching and Voltaren (diclofenac, an NSAID) was prescribed.

During the 6 February 2003 MEB examination (recorded on DD Forms 2807-1 and 2808), 4 months prior to separation, the CI reported calcium deposits in the feet, tight Achilles tendons, and a deformed ankle. Physical examination showed minimal edema of the right medial malleolus. There was a full ROM of the ankles and feet bilaterally. Arches were within normal limits bilaterally. At an orthopedic examination on 11 February 2003 the CI reported Voltaren intolerance and he was unable to keep the physical therapy appointment. He noted right ankle, tibia, and hip pain. A talar dome lesion was suspected since the CI had complete relief of ankle pain after an anesthetic (Marcaine) injection. A bone scan dated 18 February 2003 of the pelvis and lower extremities revealed a stress fracture in the mid shaft of the right fibula and a nearly healed stress fracture of the proximal portion of the right fibula. There was no evidence of a tibial stress fracture. No comment was addressed in regard to the feet. At an orthopedic visit on 17 March 2003 the CI complained of bilateral foot pain, right ankle pain, and bilateral knee pain. Magnetic resonance imaging of the right ankle was normal. There was no objective orthopedic diagnosis for the joint pain of unknown etiology.

The 3 March 2003 MEB NARSUM examination, 2 months prior to separation, noted complaints of chronic foot pain. Physical examination revealed a normal gait. There was no ecchymosis, swelling or tenderness of the feet and there was a full ROM of the ankles and feet bilaterally. The Achilles tendons were intact. There was slight pain on dorsiflexion against resistance.

At the 11 December 2003 VA Compensation and Pension evaluation, almost 7 months after separation, the CI reported pain in the feet of about a 2/10 (10 being the worst pain) and stiffness in the evening after working. He did not use any crutches, braces, canes, or corrective shoes. Physical examination showed short Achilles tendons. There was some pain on the medial malleolus (inner ankle) on the right and none on the left. Metatarsophalangeal joints were essentially negative. Feet were cool to warm proximally to distally and mild redness was noted on the upper portion of the feet. ROM of the ankle was diminished. Dorsiflexion was near absent and he had normal plantar flexion. After repetitive motion there was no objective evidence of pain, loss of function, loss of motion, or incoordination. The examiner estimated the CI would lose less than 10% of his normal ROM during a flare. There was no heel pain and the CI was able

to walk on his toes, stand on his toes, and walk on his heels. The examiner’s diagnosis was bilateral metatarsalgia.

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the bilateral foot pain condition 10%, coded 5099-5003 (arthritis, degenerative), citing the U.S. Army Physical Disability Agency pain policy as slight/constant. The VA also rated the bilateral metatarsalgia condition 10%, coded 5299-5279 (metatarsalgia, anterior (Morton’s disease), unilateral, or bilateral) based on the C&P examination almost 7 months after separation, citing the CI had continuous pain in his feet and the rating was assigned for anterior metatarsalgia.

The panel first considered if the right or left foot condition, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above. In this case, a bilateral condition was profiled, and the bilateral foot pain condition was implicated by the NARSUM and in the commander’s statement. There are no distinctions with regard to clinical features or fitness considerations between the right and left feet, although the right foot symptoms were present for a longer time. The bilateral diagnosis supported a single 5003 based rating for “2 or more major joints” without compensable limitations or painful motion; thus there is VASRD §4.71a latitude for a bilateral rating, albeit there was metatarsal pain, but not joint pain per se. Nevertheless, members agreed the evidence did not support recommending separate right and left foot disability ratings. Members noted the VA used code 5299-5279 for bilateral metatarsalgia with a rating of 10%, which affords no additional benefit to the CI. Panel members were also cognizant that on dorsiflexion against resistance there was slight pain at the NARSUM examination. However, members did not feel that there was sufficient pain to warrant a separate rating for each 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 condition.

BOARD FINDINGS: In the matter of the bilateral foot pain condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication. 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 20150613, w/atchs Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans Affairs Treatment Record

AR20170013248, 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,