RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2016-01662
BRANCH OF SERVICE:  ARMY 	SEPARATION DATE:  20040623

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E1, Health Care Specialist, medically separated for “bilateral foot pain with foot deformity” with a disability rating of 0%.  

CI CONTENTION:  Review his mental health condition.  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.  The bipolar condition is outside the panel’s defined scope of review but remains 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 – 20040319	VARD - NA	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Foot Pain with Foot Deformity (Equinus Deformity and Bunions)	5099-5003	0%	No VA Examination Proximate to Separation in Evidence	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:   NA	

ANALYSIS SUMMARY:  

Bilateral Foot Pain with Foot Deformity (Equinus Deformity and Bunions).  The PEB combined the bilateral foot and ankle conditions under a single disability rating, coded analogously to 5003 and rated 0%.  The PEB additionally declared the bilateral bunion condition not unfitting and then included the bunions in the description of the combined foot condition, substituting it for the bilateral hallux limitus condition.  This 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 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 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.  

Bilateral Foot Pain.  According to the service treatment record  (STR) and Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI complained of right foot pain, without trauma, in January 2003 during the 5th week of basic training.  Right foot X-rays on 15 January 2003 revealed a hallux valgus deformity (bunion) without fracture; and 23 January 2003 X-rays showed an early stress fracture of the proximal shaft of the 4th metatarsal towards the lateral aspect, but were otherwise normal for other bones and joints.  Foot X-rays on 15 July 2003 showed stress fractures at the proximal fourth metatarsal bilaterally and mild pes planus (flat feet).  X-rays on 2 October 2003 were again consistent with stress fractures of the bilateral 4th metatarsal base without significant interval change.  

The 18 August 2003 podiatry evaluation noted findings of mild bilateral hallux valgus and supple flat foot.  The only tenderness observed was over the shaft of the 4th metatarsal.  The 14 and 21 October 2003 podiatry examinations recorded a mild cavus foot structure (the opposite of planus or flat foot) and bilateral hallux valgus.  

During the 4 February 2004 MEB NARSUM examination, 5 months prior to separation, the CI reported bilateral foot pain which prevented him from lifting heavy objects, stand for prolonged periods, drive military vehicles or walk greater than a mile.  Physical examination showed bilateral bunions with tenderness over the medial prominence of the 1st metatarsal head bilaterally.  Range of motion (ROM) of the 1st metatarsal joint was 10 degrees of dorsiflexion and 25 degrees of plantarflexion bilaterally without pain or crepitus throughout the range.  There was no VA examination in evidence proximate to separation. 

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral foot pain with foot and ankle deformity condition 0%, coded 5099-5003 (analogous to degenerative arthritis).  Members first considered whether the right and left foot conditions, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  In this case, both feet were considered to fail retention standards and were implicated by the NARSUM, the profile and the commander’s statement.  Review of the STR evidence shows that although the condition began with the right foot, the majority of the visits were for bilateral foot pain.  Since undue speculation would be required to conclude that impairment from either would not have unacceptably interfered with specialty performance, members agreed that each foot was reasonably justified as separately unfitting.  

The panel next addressed ratings for each unfitting foot.  There was no evidence of claw foot (5278), hammer toe (5282) or severe hallux valgus (5280) in either foot to justify a rating under the respective codes.  There was no evidence of metatarsalgia to substantiate a 10% rating using code 5279 which specifies a unilateral or bilateral condition.  The panel noted that hallux limitus (5281) is rated as hallux valgus (5280), but that there was no evidence of an operation to resect the metatarsal head, and thus the disability did not rise to the level of “severe” to justify a rating under that code.  Although there were stress fractures that had not healed (nonunion) (5283) for many months in both feet, the panel agreed that due to multiple painful conditions of each foot, the disability was better characterized by code 5284 (foot injuries, other) and categorized as a “moderate” 10% rating for each foot.  There was limited evidence of acquired flat foot (5276) with pain on manipulation or use of the foot to substantiate a unilateral or bilateral 10% rating, but the panel noted that this would provide a rating disadvantage 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 each foot, coded 5284.  

Bilateral Ankle Equinus Deformity.  According to the STR and MEB NARSUM, the CI’s equinus deformity was first noted on the MEB NARSUM examination.  Review of the entire STR found only one reference to ankle pain with no examination of the ankles and no associated diagnosis.  Right foot and leg X-rays on 15 January 2003 and 23 January 2003, and bilateral foot X-rays on 15 July 2003 and 2 October 2003, showed no bony changes to the distal tibia or the talus which would contribute to a bony equinus deformity.  

At the 15 July 2003 primary care visit, 11 months prior to separation, the CI complained of bilateral foot, ankle and heel pain.  Physical examination showed “good gait” with foot abnormalities noted, but no ankle or Achilles tendon examination.  Podiatry evaluations on 2, 14 and 21 October 2003 did not record any ankle complaints, ROM measurements or Achilles tendon examination.  The 8 December 2003 and 10 May 2004 internal medicine evaluations, 6 and 1 months prior to separation, respectively, documented a normal gait.  

During the 4 February 2004 MEB NARSUM examination the CI reported bilateral foot pain, but no complaints concerning the ankles were recorded.  Bilateral ankle ROM was 5 degrees (normal 20) of dorsiflexion with the knee extended, and 10 degrees with the knee flexed.  There were no examinations of the Achilles tendons, gastrocnemius or soleus muscles.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral foot pain with foot and ankle deformity 0%, coded 5099-5003.  Panel members considered whether the right and left ankle conditions, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  Equinus deformity was not implicated in any profile or the commander’s statement, and review of the STR found no performance-based evidence that the condition interfered with satisfactory duty performance at separation; accordingly the panel cannot recommend a separate rating for it.  

BOARD FINDINGS:  In the matter of the bilateral foot pain with deformity condition, the panel unanimously recommends a disability rating of 10% for each, coded 5284 IAW VASRD §4.71a.  In the matter of the bilateral equinus deformity condition the panel unanimously agrees that it cannot recommend a finding of unfit for additional disability rating.  There are no other conditions within the panel’s scope of review for consideration.  

The panel recommends t the CI’s prior determination be modified as follows, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Right Foot Pain with Deformity	5284	10%	
Left Foot Pain with Deformity	5284	10%	
COMBINED	20%	

The following documentary evidence was considered:
	
Exhibit A.  DD Form 294, dated 20161031, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record  

AR20180002570, 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