RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2016-01313
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20040512

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a Reserve E5, Nuclear Medicine Specialist, medically separated for “coronary artery disease” and “bilateral pes planus with plantar fasciitis,” rated 10% and 0%, respectively, with a combined disability rating of 10%.  

CI CONTENTION:  His heart condition continues to worsen.  He was not evaluated for PTSD, hypertension, diabetes, high cholesterol, low back pain secondary to his feet problems, neuropathy, and nerve disorder 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 - 20040326 	VARD - 20050307	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Coronary Artery Disease	7005	10%	Coronary Artery Disease	7005	10%	20050122	
Bilateral Pes Planus with Plantar Fasciitis	5299-5276
5399- 5310	0%	Bilateral Pes Planus with Plantar Fasciitis	5276	10%	20050122	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  30% 	

ANALYSIS SUMMARY:  

Coronary Artery Disease.  According to the service treatment record (STR) and Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI suffered an acute myocardial infarction (heart attack) in October 2003 while on convalescent leave for a foot condition.  He was taken to the catheterization lab where a coronary angiography revealed 100 percent mid-right coronary artery (RCA) blockage which was treated with balloon angioplasty and implantation of a drug-eluting (coated) stent to the mid-RCA.  He tolerated the procedure well without complication and was noted to have normal left ventricular function.  A cardiolite stress test (nuclear medicine study) on 12 December 2003 was normal without a reversible ischemia or infarct.  The CI achieved 11 METS (estimated exercise tolerance) without chest pain.  Noted in the record was that the CI smoked cigarettes and had been placed on high blood pressure medications prior to activation.

During the 8 January 2004 MEB NARSUM cardiology addendum, 4 months prior to separation, the CI denied symptoms.  His functional status was thought to be excellent considering a recent myocardial infarction.  The cardiovascular examination was normal other than a slightly elevated blood pressure of 146/71.  The panel observed that cardiac hypertrophy was not recorded on this examination nor present on the catheterization, echocardiogram, or stress test procedures.  At the 22 January 2004 MEB NARSUM examination, the CI reported having exertional chest pain when he was “upset or stressed out.”  It was recorded the CI had essentially failed a trial of duty due to the exertional chest pain and foot conditions.  During a VA cardiac examination on 10 December 2004, 7 months after separation, the CI had a normal ejection fraction (percentage of blood leaving the heart each time it contracts) from 55-60%, the left ventricular wall had a mild concentric hypertrophy with the left ventricle overall normal in size, and the wall motion was normal.  

At the 22 January 2005 VA Compensation and Pension (C&P) evaluation, 8 months after separation, the CI reported occasional chest pain with exertion which was relieved with rest.  He reported a recently performed exercise stress test was normal; this was not consistent with cardiogenic chest pain (angina).  He continued to smoke, but had decreased his use.  Physical examination showed a blood pressure increase from 140/80 to 150/70 and a weight increase from 230 to 245 pounds as reported on the MEB NARSUM and VA examinations, respectfully.  The remainder of the cardiac examination was normal.  The panel observed multiple evaluations performed in 2009, 2011, and 2012 revealed no evidence of a hypertrophy but showed improved blood pressure control; the December 2004 echocardiogram was positive for hypertrophy.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the coronary artery disease condition 10%, coded 7005 (arteriosclerotic (atherosclerotic) heart disease (coronary artery disease)), citing 11 METS on exercise testing and continuous medication required.  The VA also rated the coronary artery disease condition 10%, coded 7005, based on the C&P examination 8 months after separation, and citing 8-10 METs.

The panel agreed a 10% rating under code 7005 is supported by the documented use of continuous medications and by the VA examination documenting 8-10 METs.  The panel then considered if the evidence supported a higher 30% rating.  The CI reported exertional chest pain; however cardiac testing did not confirm the presence of angina to support a higher rating.  The VA cardiac examination (echocardiogram) recorded mild ventricular hypertrophy which supports a 30% rating.  However, multiple evaluations prior to this (and equally proximate to separation) did not reveal hypertrophy.  There were also evaluations remote from separation which noted the absence of ventricular hypertrophy.  The medical officer observed that the concentric hypertrophy noted on the VA echocardiogram, 7 months after separation, is typically secondary to hypertension and the CI had better control of this in the years following the C&P examination.  As such, the panel determined the sole finding of hypertrophy was either an outlier or a temporary reflection of poor blood pressure control which then resolved with better control.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded there was insufficient cause to recommend a change in the PEB adjudication for the coronary artery disease condition.  

Bilateral Pes Planus with Plantar Fasciitis.  According to the STR and MEB NARSUM, the CI was medically evacuated from Iraq in September 2003 due to bilateral foot pain which he attributed to walking and running on desert sand.  He was issued orthotics and placed on convalescent leave during which time he experienced a heart attack. 

The 22 January 2004 MEB NARSUM general examination, 4 months prior to separation, noted symptomatic plantar fasciitis and pes planus (flat feet) which limited walking to approximately half a mile and an inability to run.  Physical examination showed bilateral foot tenderness with symptomatic plantar fasciitis and moderately severe pes planus.  

At the C&P evaluation the CI reported severe, left greater than right, foot pain occurring every morning when he got out of bed and aggravated by long periods of activity and standing.  Additionally, he was unable to stand and walk for long distances due to pain.  Physical examination showed a normal gait.  The neurologic examination was grossly intact.  Severe bilateral flat foot deformities were present.  There was bilateral plantar, medial heel and plantar arch tenderness, left greater than right.  Marked swelling, deformity, or callouses were not recorded.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral foot condition 0%, analogously coded 5276 (flatfoot, acquired), citing slight pain with likely application of the US Army Physical Disability Agency pain policy.  The VA rated the bilateral foot condition 10%, coded 5276, based on the C&P examination 8 months after separation, citing a 10% rating assigned whenever the weight-bearing line is over or medial to the great toe with inward bowing of the tendo-achillis, and there is pain on manipulation and use of the feet.  

The panel determined the MEB NARSUM and C&P examination evidence supports a 10% rating, but did not rise to a higher level of impairment.  Code  5310 (Group X muscle function…plantar fascia) was considered but a normal gait supports no higher than a 10% moderate level of impairment and offers no advantage to the CI.  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 bilateral foot condition, coded 5276.  

BOARD FINDINGS:  In the matter of the coronary artery disease condition and IAW VASRD §4.104, the panel unanimously recommends no change in the PEB adjudication.  In the matter of the bilateral foot condition, the panel unanimously recommends a disability rating of 10%, coded 5276 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	
Coronary Artery Disease	7005	10%	
Bilateral Pes Planus with Plantar Fasciitis	5276	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20161001, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record 

AR20180001949, XXXXXXXXXXXXXXXXXX 

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX:

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