RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-00734
BRANCH OF SERVICE:  army 	SEPARATION DATE:  20050308

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Petroleum Supply Specialist, medically separated for “chronic back and heel pain” with a disability rating of 10%.  “Bilateral hallux valgus” was determined to have existed prior to service (EPTS) and was not rated.

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 Medical Evaluation Board (MEB), but determined by the PEB 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.  The panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections when appropriate.  The panel’s assessment of the PEB rating determination is based on review of medical records and all available evidence relevant to application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards for 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, which operates 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 disability at the time of separation.  

RATING COMPARISON:  

SERVICE PEB - 20050113	VARD - 20060606	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Back and Heel Pain	5237	10%	Chronic Mechanical Low Back Pain	5237	20%	20060310	
Bilateral Hallux Valgus with Bilateral Heel Pain	5299-5276	EPTS	Bilateral Foot Disability	5299-5279	10%	20060310	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Chronic Back and Heel Pain.  The PEB combined the back and heel conditions under a single disability rating, coded 5237 and rated 10%.  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’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.  The evidence for the back and heel conditions are presented separately, with attendant recommendations regarding separate unfitness, and separate rating if indicated. 

According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s back condition began in August 2002 during his initial entry training, with no acute injury noted.  The 2 May 2004 orthopedic examination noted complaints of chronic lower back pain.  Physical examination showed a normal gait.  There was mild tenderness over the right lumbar paraspinal region.  Range of motion (ROM) was flexion to 95 degrees (normal 90) and pain in most planes of motion.  

The 16 September 2004 physical therapy examination, 6 months prior to separation, noted complaints of 5/10 chronic lower back pain.  Thoracolumbar ROM was noted as forward flexion to 85 degrees, and combined ROM of 235 degrees (normal 240).  There was pain noted at the end of ROM in all planes except for extension and left lateral flexion.  The 18 November 2004 MEB NARSUM examination, 4 months prior to separation, noted complaints of persistent lower back pain.  Physical examination showed a normal gait.  There was decreased lumbosacral ROM and right sacroiliac joint tenderness to palpation.  

At a VA primary care evaluation, 9 March 2005, 1 day after separation, the CI reported chronic lower back pain.  He denied radicular symptoms.  Physical examination showed full musculoskeletal ROM.  At a VA primary care evaluation, 29 March 2005, 3 weeks after separation, the CI reported 7/10 low back pain.  He denied pain radiation and bowel or bladder involvement.  The pain worsened with flexion and climbing stairs.  Physical examination showed forward flexion to 60 degrees and extension to 15 degrees. There was flattening of the lumbar lordosis and pain on palpation of right lumbar paraspinal muscles.  The gait was normal.  

At the 15 March 2006 VA Compensation and Pension (C&P) spine evaluation, 12 months after separation, the CI reported 5/10 right lumbar pain.  ROM testing showed forward flexion of 40 degrees and combined ROM of 150 degrees.  The spinal appearance and gait were normal.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 10%, coded 5237 (lumbosacral strain), citing ROM limited by pain and combined passive ROM of 225 degrees.  The VA rated the back condition 20%, coded 5237, based on the C&P examination, citing VASRD rating criteria.  The panel first considered if the back condition, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  In this case, the back condition was profiled, considered to fail retention standards and implicated by the NARSUM and commander’s statement.  Panel members agreed the evidence reasonably justified that the functional limitations of the back condition contributed to the CI’s inability to perform his military duties, and accordingly a separate disability rating is recommended.  

Although there was post-separation evidence of forward flexion between 31-60 degrees, the preponderance of ROM evidence supports a 10% rating for limitation of flexion (greater than 60 degrees but not greater than 85 degrees).  There was no muscle spasm or guarding severe enough to result in an abnormal gait or spinal contour and the combined ROM was greater than 120 degrees in all examination proximate to separation so a 20% rating was not supported.  After due deliberation, and considering all of the evidence, the panel recommends a separately unfit determination with a disability rating of 10% for the back condition, coded 5237.  

Heel Pain.  According to the STR and the MEB NARSUM, the CI’s bilateral heel condition began in July 2004 when he reported bilateral heel pain two weeks after running in boots.  X-ray evaluation of the left foot was normal.  The 24 August 2004 podiatric evaluation noted a history of gradual onset of bilateral foot pain.  The pain was worse with weight bearing, standing, running and jumping.  Physical examination showed tenderness of the Achilles tendon and calcaneal tuberosity bilaterally.  There was swelling of the calcaneal and retrocalcaneal bursa bilaterally.  There was hallux valgus deformity (bunion) bilaterally.  The examiner rendered a diagnoses of bursitis, enthesopathy (dysfunction of the bone/tendon junction), and rule out calcaneal spur.  The 18 November 2004 MEB NARSUM examination noted diagnoses of calcaneal spurs and Achilles tendonitis.  The examiner noted the CI was treated with “orthotics and nonsteroidal medication with mixed results.”  Physical examination showed bilateral pes planus.  

At the 10 March 2006 C&P foot evaluation the CI reported occasional swelling at the heels and 6/10 heel pain.  Physical examination showed a normal gait. There was mild hallux valgus deformity bilaterally that was non-tender to palpation and motion.  There was pain at the heels with dorsiflexion and mild swelling at the retrocalcaneal and posterior heel.  The examiner rendered diagnoses of retrocalcaneal bursitis, plantar fasciitis (heel spur syndrome) and mild hallux valgus deformity.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the heel condition as mentioned above.  The VA rated the bilateral heel condition 10%, coded 5299-5279, (analogous to metatarsalgia, anterior (Morton’s disease), unilateral, or bilateral), based on the C&P examination.  

The panel first considered if the heel condition, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  In this case, bilateral heel (foot) pain condition was considered to fail retention standards, implicated by the NARSUM, and temporarily profiled.  Panel members agreed the evidence reasonably justified that the functional limitations of the heel condition contributed to the CI’s inability to perform his military duties, and accordingly a separate disability rating is recommended.

The panel noted that the bilateral heel pain was attributed to retrocalcaneal (behind the calcaneus) bursitis and plantar fasciitis.  The panel noted there was pain with use and manipulation of the heels to warrant a 10% rating for moderated bilateral foot disability coded analogously to 5276 (acquired flat feet).  The evidence did not support a 10% rating for each foot for painful motion (5019-5024), loss of motion of the ankles, or moderate foot injury (5284).  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 heel condition, coded 5299-5276.  

Contended PEB Condition:  Bilateral Hallux Valgus.  The panel’s main charge is to assess the fairness of the PEB’s determination that the contended EPTS condition was not permanently service aggravated and not ratable.  Panel members agreed that due to the natural progression of hallux valgus deformities (bunions), this condition was EPTS and not permanently service aggravated.  After due deliberation, the panel concluded there was insufficient cause to recommend a change in the PEB compensability determination for the contended condition and so no additional disability rating is recommended.  

BOARD FINDINGS:  In the matter of the back condition, the panel recommends a disability rating of 10%, coded 5237 IAW VASRD §4.71a.  In the matter of the bilateral heel condition, the panel determined that that it was unfitting and recommends a disability rating of 10%, coded 5299-5276 IAW VASRD §4.71a.  In the matter of the contended EPTS bilateral hallux valgus condition, the panel agrees it cannot recommend it for additional disability.  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	
Chronic Back Pain	5237	10%	
Bilateral Heel Pain	5299-5276	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20170215, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record 

AR20180004797, 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