1RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2016-01221
BRANCH OF SERVICE:  ARMY 	SEPARATION DATE:  20040525

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a National Guard E1, Trainee, medically separated for “chronic bilateral foot/ankle pain secondary to stress fractures of the bilateral talus” with a disability rating of 0%.  

CI CONTENTION:  “Secondary disability not rated for.”  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 - 20040416	VARD - 20040910	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Bilateral Foot/Ankle Pain Secondary to Stress Fractures of the Bilateral Talus	5022	0%	Bilateral Navicular Stress Fractures	5099-5010	20%	20040706	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Chronic Bilateral Foot/Ankle Pain Secondary to Stress Fractures of the Bilateral Talus.  The PEB combined the left foot/ankle and right foot/ankle conditions as a single unfitting condition coded 5022 (periostitis) and rated 0%.  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 left foot/ankle and right foot/ankle conditions are presented together, with attendant recommendations regarding separate unfitness, and separate rating if indicated.  

According to the service treatment record (STR) and Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s bilateral foot/ankle condition began in September 2003 during basic training.   On 1 October 2003, X-rays showed normal feet and legs, and a 21 October 2003 right ankle X-ray showed no evidence of fracture or dislocation.  The CI continued to experience bilateral foot and ankle pain, right greater than left, and was diagnosed by a podiatrist in November 2003 with stress fractures to the navicular bones.  Physical therapy, activity limitations, and medication did not alleviate her pain, and she was unable to return to training.  

A 20 November 2003 bone scan showed markedly intense uptake in the anterior aspect of each talus with an impression of severe stress fracture changes.  Podiatry, physical therapy (PT), and occupational therapy appointments during the late 2003 to early 2004 timeframe (12 December 2003, 5 January 2004, 15 January 2004) recorded normal or full ankle range of motion (ROM) without providing measurements.  Follow-up bone scans in January and March of 2004 confirmed anterior talar stress fractures, right worse than left.  At a 29 January 2004 PT visit,  4 months before separation and 6 weeks before the NARSUM examination, ROM measurements showed right ankle dorsiflexion of 20 degrees (normal) and plantar flexion of 20 degrees (normal 45), with left ankle dorsiflexion of 20 degrees and plantar flexion of 28 degrees.  

The 10 March 2004 MEB NARSUM examination, 2 months prior to separation, noted complaints of bilateral pain rated at 3/10 when sitting, but worsened to 8 or 9/10 with prolonged standing, walking, squatting, marching, and running.  X-rays were normal.  Physical examination showed pain to palpation to the navicular bones bilaterally, right greater than left, with some discomfort at the talonavicular joint as well.  There was no pain with ankle or subtalar joint range of motion, but no measurements were recorded.    

At the 6 July 2004 VA Compensation and Pension (C&P) evaluation, 2 months after separation, the CI reported pain that did not cause incapacitation but prevented running, and walking or standing for long periods.  Physical examination showed normal gait, posture and ROM (dorsiflexion of 20 degrees and plantar flexion of 45 degrees, with pain at those ranges for each ankle).  ROM was not additionally limited by pain, fatigue, weakness, lack of endurance, or incoordination.  

The panel directed attention to its rating recommendation based on the above evidence.  As noted above, the PEB bundled the right foot/ankle condition with the left foot/ankle condition and applied a single 0% rating coded 5022 (periostitis).  The VA rated the bilateral foot/ankle condition 20%, analogously coded 5099-5010, (arthritis, due to trauma) based on the C&P examination 2 months after separation, citing X-ray evidence showing involvement of two or more major joints or two or more minor joints with occasional incapacitating exacerbations.  

The profile and other STR evidence did not provide any information which would permit the panel to discriminate the performance limitations of either foot/ankle over the other.  There were no distinctions with regards to clinical features or fitness considerations between the two lower extremities, and the panel determined that the effect of both feet/ankles reasonably rendered the CI unfit, and that each was separately unfitting.  

The panel then considered whether each foot/ankle, rated separately, met the criteria for a compensable rating.  Members noted the PT ROM measurements taken 4 months before separation warranted consideration for a 10% rating for moderate limitation of motion of each ankle.  The VA evaluation, 2 months post-separation, showed full ankle ROM with pain at the normal limits bilaterally.  This also warranted consideration of a 10% rating under §4.59 (painful motion) of each ankle.  The panel concluded that either examination supported a minimum 10% rating for each foot/ankle based on either loss of motion or functional loss/painful motion.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 10% for the right foot/ankle condition, coded 5022-5271 and a disability rating of 10% for the left foot/ankle condition, coded 5022-5271.  

BOARD FINDINGS:  In the matter of the bilateral foot/ankle pain condition, the panel unanimously recommends that each joint be separately adjudicated as follows:  an unfitting right foot/ankle condition coded 5022-5271 and rated 10%, and an unfitting left foot/ankle condition, coded 5022-5271 and rated 10%, both IAW VASRD §4.71a.  There are no other conditions within the panel’s scope of review for consideration.  

The panel recommends the CI’s prior determination be modified as follows, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Chronic Right Foot/Ankle Pain Secondary to Stress Fractures of the Right Talus	5022-5271	10%	
Chronic Left Foot/Ankle Pain Secondary to Stress Fractures of the Left Talus	5022-5271	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20160705, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record 

AR20170018942, 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