RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX 	CASE:  pd-2016-00343
BRANCH OF SERVICE:   Army 	SEPARATION DATE:  20051013

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an Army active duty E2, Field Artillery Radar Operator, medically separated for “left heel pain” with a disability rating of 0%.  

CI CONTENTION:  His condition continues to worsen.  The 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 - 20050923	VARD - 20051108	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Heel Pain Secondary to Stress Reaction	5022	0%	Bursitis, Left Heel 	5019-5284	10%	20050907	
			Stress Changes L Tibia w/ Ankle Strain	5262	10%	20050907	
RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Left Heel Pain Secondary to Stress Reaction.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI suffered an onset of left foot and ankle pain in February 2005 (8 months before separation) during a road march in basic training.  A bone scan was consistent with a stress fracture of the calcaneus.  Follow-up X-rays were normal, although a repeat bone scan in June still showed some residual uptake.  There were no surgical indications, and there was insufficient improvement to permit a timely resumption of training.  There was documentation in STR clinical entries of normal ankle range of motion (ROM) and there were no entries to the contrary, although painful motion was in evidence.  There were variable entries with regard to gait disturbance, and the only consistent positive examination finding was heel tenderness.  There were no entries that indicated serious functional impairment, and there was no documentation of any additional VASRD-ratable findings or alternate foot diagnosis linked to a specific VASRD code.  The 2 August 2005 NARSUM examination, 10 weeks prior to separation, documented nonspecific “chronic left foot pain” that was exacerbated by prolonged standing and prohibited most general soldiering requirements.  The physical examination recorded an antalgic gait, heel tenderness, and intact neurovascular findings.  There was no formal goniometric ROM evidence in the STR.  

The 7 September 2005 VA Compensation and Pension (C&P) examination, a month before separation, separately documented left “lower leg,” ankle, and heel conditions.  The left “lower leg” condition was ascribed to additional bone scan findings of stress fractures (tibial plateau and tuberosity) that were reported on the initial bone scan, although not present on the repeat scan.  It should be noted that these findings are contiguous to the knee, that no knee complaints were referenced, and that a normal knee examination was in evidence (including normal measured ROM without pain).  The left ankle pain was characterized as intermittent and the heel pain as constant, and neither was quantified.  Both hurt with running and the heel pain was aggravated by standing or walking.  The physical examination recorded a normal gait, no swelling, the absence of ankle or foot tenderness, and the absence of any ratable foot deformities.  Measured ankle ROM was dorsiflexion to 18 degrees (normal 20) and plantar flexion to 42 degrees (normal 45), specifying pain at end ranges.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB’s 0% rating under code 5022 (periostitis) cited normal ROM without addressing painful motion.  The VA, based on the C&P evidence, conferred separate ratings for the heel and ankle.  The heel was rated 10% under code 5019-5284 (bursitis rated as ‘foot injuries, other’) citing failure to achieve the 20% criterion of code 5284 for “moderately severe” disability.  The 10% criterion of Code 5284 is “moderate” disability, and the 30% criterion is “severe.”  The ankle condition was erroneously attributed to the tibial bone scan findings as elaborated above.  It was rated 10% under code 5262 (tibia and fibula, impairment of) that specifies nonunion or malunion of fractures and offers ratings for contiguous ankle disability.  The VA rater cited failure to achieve the 20% criterion of code 5262 for “moderate” joint disability.  The 10% criterion of Code 5284 is “slight” disability, and the 30% criterion is “marked.”

Notwithstanding the VA’s linkage of the ankle pain with tibial pathology referable to the knee, compounded by the dubious applicability of code 5262 for even that pathology; the panel agreed that separately ratable impairment of the foot and ankle could not be proposed in this case without violating VASRD §4.14 (avoidance of pyramiding).  

Having agreed that separate ratings were not justified, members turned to deliberation of the optimal code and fairest rating for the foot condition (subsuming the ankle pain).  The PEB’s coding choice for periostitis (defaulting to criteria of code 5003 [degenerative arthritis]) was clinically compatible with the pathology; but, as noted above, the PEB’s 0% rating did not account for VASRD §4.59 which stipulates the minimum compensable rating for painful motion.  Members agreed that that there was satisfactory evidence of painful motion, both in the STR and as specified in the pre-separation C&P examination; thus, the minimum 10% rating was supported. 

Rating under code 5284 alone was defensible, although members agreed that analogous rating under code 5262 (with its somewhat more generous criteria) was not justified by VASRD §4.20 (analogous ratings) in a case such as this which satisfies compensable criteria under more applicable codes.  With regard to rating under 5284, members agreed that the disability in evidence could not be reasonably characterized as more than moderate; thus, it was not favorable.  Rating under code 5271 (limitation of motion) would require application of §4.59 to support the minimum 10% rating; thus, it was not favorable.  There was no evidence for any ratable criterion or separately coded foot diagnosis that would justify a rating higher than 10% under any other applicable code available in VASRD §4.71a.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a 10% rating for the left calcaneal condition under code 5022.

BOARD FINDINGS:  In the matter of the left calcaneal condition (subsuming ankle pain), the panel unanimously recommends a disability rating of 10%, coded 5022 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	
Periosteal Injury, Left Calcaneus	5022	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20160529, with attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record 

AR20170015411, 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