RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2016-01486
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20040422

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 “chronic stress fracture metatarsals left foot” with a disability rating of 0%.  

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 -200403019	VARD - 20041213	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Stress Fracture Metatarsals Left Foot	5099-5003	0%	Chronic  Stress Fractures of the Feet	5284	NSC	20040727	
Hallux Valgus	Not Unfitting	Left Foot Hallux Valgus	5280	0%	20040727	
Pes Planus	Not Unfitting	Pes Planus, Bilateral	5276	0%	20040727	
	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Chronic Stress Fracture Metatarsals Left Foot.  According to the service treatment record (STR) and Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s left foot condition began in September 2003 while in basic training without trauma.  At a podiatry clinic visit on 22 September 2003 the CI reported left foot pain for over 2 weeks. On examination she was tender on the third metatarsal with swelling.  The examiner’s assessment was a stress fracture of the third metatarsal.  The CI was seen in follow-up on 21 October 2003, at which time she was without pain to palpation at the fracture site and an X-ray showed a well-healing stress fracture.  She did have pain to palpation at the first metatarsal at the site of a bunion. The examiner’s assessment was “healing stress fracture” and the CI was returned to duty.  At a soldier and family medicine clinic visit on 12 January 2004 the CI complained of foot pain for 5 months.  She had tenderness of the metatarsal bones of both feet.  Treatment consisted of tramadol (an opioid-like medication).  A bone scan on 12 January 2004 was interpreted as consistent with a stress fracture in the left foot.    At a follow-up podiatry visit on 15 January 2004 the examiner noted a closed stress fracture of the third left metatarsal shaft, which was well healed, and a hammer toe on the right.  On 20 January 2004, the podiatrist noted the stress fracture was improving though not completely resolved.  A bone densitometry study was normal with findings consistent with normal bone mass and normal fracture risk.  There was no significant osteoarthritis/bone remodeling.  The podiatrist opined “full recovery expected.”  However, the CI was seen in the podiatry clinic on 26 January 2004 at which time she complained of a chronic stress fracture of the left foot aggravated by military boot wear.   The CI was dropped from training and a P3 profile was generated.  

During the 1 March 2004 MEB examination (recorded on DD Forms 2807-1 and 2808) 1 month prior to separation, the CI reported “stress fracture in left foot.”  The examiner noted a chronic left foot stress fracture.  The 3 March 2004 MEB NARSUM examination noted complaints of left leg and foot pain.  Physical examination showed significant tenderness about the third metatarsophalangeal joints.  The examiner noted the CI was partial weight bearing in a CAM (controlled ankle motion) walker and was unable to perform any of her duties.  His diagnosis was chronic stress fracture, left foot, currently symptomatic.  

At the 27 July 2004 VA Compensation and Pension (C&P) evaluation, 3 months after separation, the CI reported pain at rest, weakness, stiffness, and fatigue.  While standing or walking she had pain when moving the third metatarsal.  Physical examination of the left foot showed a slight degree of valgus, which could be corrected by manipulation.  There was no forefoot/midfoot malalignment.  There was a deformity of medial tilting of the upper border of the talus.  She did not have any limitation with standing and walking and did not require any type of support with her shoes.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the chronic stress fracture metatarsals left foot condition 0%, coded 5099-5003 (arthritis, degenerative), citing “confirmed on bone scan and X-ray.”  The VA determined the chronic stress fractures of the feet were not service-connected based on the C&P examination, citing “although there is a record of treatment in service for a stress fracture of the left foot, no permanent residual or chronic disability subject to service connection is shown by the STRs or demonstrated by evidence following service.”  

The podiatrist noted the stress fracture was improving and a full recovery was expected.  However the CI subsequently complained of a chronic stress fracture of the left foot aggravated by military boot wear.   Three months post-separation she had pain while standing or walking when moving the third metatarsal and joint around the third toe of the left foot, evidence of residual involvement of the left third metatarsal fracture.  Thus, members determined a rating of 10%, and no higher, was appropriate, using code 5283 (tarsal, or metatarsal bones, malunion of, or nonunion of) for moderate disability.  Members noted that although an X-ray showed healing, a bone scan showed persistence of the fracture, and the CI was still symptomatic.  Code 5284 likewise offers a 10% rating; however, code 5283 was more precise and therefore more applicable.  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 chronic stress fracture metatarsal left foot condition, coded 5283.  

Contended PEB Conditions:  Pes Planus and Hallux Valgus.  The panel’s main charge is to assess the fairness of the PEB’s determination that the contended conditions were not unfitting.  The pes planus and hallux valgus conditions were profiled, and although not explicitly implicated in the commander’s statement, it was noted that her medical conditions prevented completion of initial entry training.  Weight bearing X-rays on 12 January 2003 demonstrated bilateral pes planus and bilateral hallux valgus.  On 20 January 2003 the CI was evaluated for bilateral hallux valgus, which was addressed conservatively by having her not wear combat boots.  

During the 1 March 2004 MEB examination, 1 month prior to separation, physical examination showed mild bilateral pes planus and bunions.  The 3 March 2004 MEB NARSUM examination, 1 month prior to separation, noted complaints of left leg and foot pain as well as bilateral bunions and flat feet.  Physical examination showed bilateral abducted hallux, low arch morphology, and pronated mid stance.  The NARSUM noted that due to the need for the stress fracture to heal, the CI was not recommended for aggressive management of her pes planus or bilateral hallux valgus.  Radiographic findings were consistent with an increased intermetatarsal angle, as well as increased hallux abductus angle bilaterally.  There was a decreased calcaneal inclination angle, consistent with low arch morphology.  The examiner noted the CI was weight bearing in a CAM walker and was unable to perform any of her duties.  His diagnoses were pes planus, symptomatic, with hyperpronation on weight bearing, which prevented the wearing of military footwear; and hallux valgus, which was moderately severe, with pronounced symptoms as well as deviation of joint structures consistent with subluxation of sesamoids. 

At the 27 July 2004 C&P evaluation the CI reported pain at rest, weakness, stiffness, and fatigue.  Physical examination of the left foot showed a slight degree of valgus, which could be corrected by manipulation.  There was no forefoot/midfoot malalignment.  There was a deformity of medial tilting of the upper border of the talus, and no tenderness of the left foot plantar surface.  The left Achilles tendon revealed good alignment.  Hallux valgus of the left foot was present; the degree of angulation was slight with no resection of the metatarsal head present.  She did not have any limitation with standing and walking and did not require any type of support with her shoes.

The VA rated the bilateral pes planus condition 0%, coded 5276 (flatfoot, acquired), based on the C&P examination, citing no signs of abnormal weight bearing and no functional impairment caused by the condition.  The VA also rated the left foot hallux valgus and the right foot hallux valgus 0% each, coded 5280 (hallux valgus, unilateral), citing that although there were subjective complaints, there were minimal findings, and a non-compensable evaluation is assigned unless the metatarsal head had been surgically resected or the condition is functionally equivalent to an amputation of the great toe.  The VA did assign a 10% evaluation based on multiple non-compensable, service-connected disabilities.

There was performance-based evidence from the record that the aforementioned conditions significantly interfered with satisfactory duty performance at separation.  After due deliberation, the panel agreed the preponderance of the evidence with regard to the functional impairment of the bilateral pes planus and bilateral hallux valgus conditions favors their addition as  unfitting conditions. Panel members determined a separate rating for each foot was warranted.  The pes planus is appropriately coded 5276 for both the right and left foot and meets the VASRD §4.71a criteria for a 0% rating for each foot.  The hallux valgus is appropriately coded 5280 for both the right and left foot and meets the VASRD §4.71a criteria for a 0% rating for each foot.  

BOARD FINDINGS:  In the matter of the chronic stress fracture metatarsals left foot condition, the panel recommends a disability rating of 10%, coded 5283 IAW VASRD §4.71a.  In the matter of the contended pes planus condition, the panel agrees it was unfitting and recommends a disability rating of 0%, coded 5276, for the right foot, and a disability rating of 0%, coded 5276, for the left foot, both  IAW VASRD §4.71a.  In the matter of the contended hallux valgus condition, the panel agrees it was unfitting and recommends a disability rating of 0%, coded 5280, for the right foot, and a disability rating of 0%, coded 5280, for the left foot, 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 the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Chronic Stress Fracture Metatarsals Left Foot	5283	10%	
Pes Planus, Right Foot	5276	0%	
Pes Planus, Left Foot	5276	0%	
Hallux Valgus, Right Foot	5280	0%	
Hallux Valgus, Left Foot	5280	0%	
COMBINED	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20161016, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record 

AR20180003426, 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