RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-02571
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20071014

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a Reserve E3, Trainee, medically separated for “left and right calcaneal stress fracture” 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 - 20070817	VARD - 20071214	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left and Right Calcaneal Stress Fracture	5009-5003	10%	Residuals, Left Foot Calcaneus Stress Fracture w/Plantar Fasciitis	5284	0%	20071024	
			Residuals, Right Foot Calcaneus Stress Fracture w/Plantar Fasciitis	5284	0%	20071024	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY.

Left and Right Calcaneal Stress Fracture.  The PEB combined the left calcaneal stress fracture and the right calcaneal stress fracture as a single unfitting condition analogously coded 5003 (degenerative arthritis) and rated 10% 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 also noted that “bundling,” the combining of two or more major joints, may be permissible under the VASRD 5003 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 the left and right calcaneal stress fractures are presented separately, with attendant recommendations regarding separate unfitness, and separate rating if indicated.

Left Calcaneal Stress Fracture.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s left foot pain condition began in October 2006 during basic training.  With conservative treatments consisting of medications, activity limiting profiles, physical therapy and orthotic shoe inserts the pain resolved after 2 ½ months allowing her to complete basic training.  Then after a 10 km foot march and 7 days of running the pain in the left heel returned.  In February 2007 a bone scan showed intense uptake of the radioactive tracer in the left calcaneus consistent with a stress fracture.  There was no surgical indication and further therapy and activity limiting profiles did not result in improvement sufficient to allow for unrestricted activity and the CI to complete her technical training.

The panel noted 8 medical visits from 7 October 2006 to 23 April 2007 which resulted in temporary profiles issued; all except 1 were for the left heel only.

The 21 May 2007 MEB NARSUM examination, 5 months prior to separation, noted complaints of left greater than right heel pain.  Pain was increased with prolonged standing or walking barefoot.  The CI reported not taking medication for the condition.  Physical examination showed tenderness with palpation to the left calcaneus and plantar fascia.

At the 24 October 2007 VA Compensation and Pension (C&P) podiatry evaluation, less than 1 month before separation, the CI reported left greater than right heel pain that was aggravated by running.  Physical examination showed tenderness limited to the plantar calcaneal tubercle (insertion of the plantar fascia) of the left foot.  Gait was normal and no painful motion was noted.

The panel first considered if the left heel pain, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  The panel found the majority of complaints, in the year prior to separation, were associated with the left heel; and all 8 temporary profiles were associated with left heel or ankle pain evaluations.  Additionally, the CI did not complete her technical training due to the inability to stand for long periods which resulted in her MEB referral.  The panel recommends the left heel pain be declared separately unfitting and rated.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the combined left and right calcaneal stress fracture condition 10%, analogously coded 5099-5003 (degenerative arthritis), citing the USAPDA pain policy.  The VA rated the left calcaneus stress fracture with plantar fasciitis condition 0%, coded 5284 (foot injuries, other), based on the C&P examination 1 month before separation, citing normal gait and weight bearing as well as absence of moderate symptoms associated with foot injury.

The panel agreed there was no evidence of fracture with malunion of the calcaneus to justify a rating using code 5273 (os calcis or astragalus, malunion of).  There was no evidence of acquired flatfoot or claw foot to validate a rating under the respective codes (5276, 5278).  Panel members agreed that the degree of severity of the CI’s condition did not rise to the level of moderate for a 10% rating under code 5284.  There was no evidence of painful motion with functional loss supporting a minimal rating (based on §4.59, §4.40 and §4.45).  No additional functional limitation was evidenced by any other examinations.  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 left calcaneus stress fracture condition.

Right Calcaneal Stress Fracture.  According to the STR and the MEB NARSUM, the CI’s right heel pain condition was first documented on 8 March 2007 as bilateral heel pain which worsened with daily ambulation.  During a 23 April 2007 primary care clinic follow-up visit the CI noted bilateral heel pain.  Physical examination showed a normal gait with bilateral foot tenderness, but bilateral foot motion was normal without painful motion.  The medical provider issued a temporary profile only listing the left heel as the area of concern; followed by temporary L3 profile on 9 May 2007.  Bilateral foot pain as permanently L3 profiled on 05 June 2007.

At a 30 July 2007 podiatry evaluation, 3 months before separation, the CI complained of left heel tenderness which improved with orthotics.  There were no right foot complaints at that visit.  The podiatrist noted that the right heel was not tender during that evaluation.  There were no subsequent STR right foot examinations in the record.

The panel first considered if the right heel pain, having been de-coupled from the combined PEB adjudication, remained separately unfitting.  The panel majority found the preponderance of evidence indicated the right heel condition would not cause the member to be referred into the DES or be found unfit because of a physical disability.  However, the panel unanimously found no performance-based evidence from the record that the condition significantly interfered with satisfactory duty performance at separation.  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 right calcaneus stress fracture condition.

BOARD FINDINGS:  In the matter of the left calcaneal stress fracture and right calcaneal stress fracture conditions 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 20150601, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170013328, XXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXX:

	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,					      
						      					
Enclosure