RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXX	CASE:  PD-2017-01052
BRANCH OF SERVICE:  army	SEPARATION DATE:  20051010

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Traffic Management Coordinator, medically separated for “left and right foot pain” with a disability rating of 0%.

CI CONTENTION:  In addition to the foot condition, the CI requested review of additional conditions not identified by the Medical Evaluation Board (MEB) and Physical Evaluation Board (PEB).  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 PEB to be unfitting for continued military service, and when specifically requested by the CI, those conditions identified by the 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 - 20080808	VARD - NA	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left and Right Foot Pain	5099-5003	0%	No VA Examination Proximate to Separation in Evidence	
Lower Limb, Reflex Sympathetic Dystrophy	Not Unfitting		
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  NA	

ANALYSIS SUMMARY:

Left and Right Foot Pain.  The PEB combined the left and right foot conditions under a single disability rating, coded analogously to 5003 and rated 0% with application of the US Army Physical Disability Agency (USAPDA) pain policy.  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.

According to the service treatment record and MEB narrative summary (NARSUM), the CI underwent left second and third toe hemiphalangectomies (bone removal) in January 2004 and right foot ganglionic cyst excision in October 2004.  The 26 January 2005 MEB NARSUM examination, 9 months prior to separation, noted complaints of left foot discomfort, decreased range of motion (ROM) and numbness.  The CI reported an inability to bend the toes of her left foot.  She tripped often, but could tolerate close-toed shoes.  Physical examination showed numbness and cooling to the forefoot area, abnormal to distal cooling.  The examiner noted the CI was a candidate for recurrent right foot ganglion cyst surgery.  

At the 8 February 2004 neurology evaluation, 8 months prior to separation, the CI reported 8/10 left greater than right foot pain, decreased left foot “sensation from the distal third to include all the toes” and the inability to dorsiflex the left second through fifth toes.  The CI also reported an abnormal gait as a result of left foot pain and numbness.   Physical examination showed incomplete dorsiflexion of the second through fifth toes on the left, normal extension and abduction. There was decreased sensation in the distal left foot both medially and laterally described as patchy (some areas where the sensation was relatively normal and other areas on the toes where it was diminished).  The examiner opined that the CI’s left foot motor dysfunction was either a result of nerve or tendon damage.  

The 6 June 2005 MEB NARSUM addendum, 4 months prior to separation, noted complaints of left foot pain discomfort, decreased ROM and numbness.  The CI reported “occasional persistent swelling on the dorsal aspect of the right foot” and “was reassured that this was a normal postoperative course.”  Physical examination was not documented. There was no VA examination proximate to separation in evidence.

The panel directed attention to its rating recommendation based on the above evidence.  As noted above, the PEB rated the left and right foot conditions 0%, analogously coded 5099-5003 (arthritis, degenerative), citing the USAPDA pain policy.  The panel first considered if the left and right foot conditions, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  In this case, each foot was profiled, implicated in the commander’s statement and noted to fail retention standards by the MEB.  Panel members agreed the evidence reasonably justified that the functional limitations of each foot individually contributed to the CI’s inability to perform her military duties, and accordingly separate disability ratings are recommended.

In considering its rating recommendation for the left foot condition, the panel noted subjective reports of pain with use and numbness confirmed on physical examination.  Multiple treatment notes documented an antalgic gait as a result of the left foot condition.  In considering its rating recommendation for the right foot condition, the panel noted the surgical history of two ganglion cyst excisions with reports of persistent right foot pain with use.  Panel members agreed that the evidence supported a 10% rating for each foot due to moderate foot injury under code 5284 (foot injuries, other).  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 10% for each foot condition, coded 5284.  

Contended PEB Condition:  Reflex Sympathetic Dystrophy (RSD) of the lower limb.  The panel’s main charge is to assess the fairness of the PEB determination that the contended condition was not unfitting.  The contended condition was not profiled or implicated in the commander’s statement, but was judged to fail retention standards.  The panel noted that the NARSUM examiner identified an RSD component to the left foot condition; however, there was insufficient performance-based evidence from the record that the condition significantly interfered with satisfactory duty performance at separation.  After due deliberation, the panel concluded there was insufficient cause to recommend a change in the PEB fitness determination for the contended condition, so no additional disability rating is recommended.  

BOARD FINDINGS:  In the matter of the left and right foot condition, the panel recommends that each joint be separately adjudicated as follows: an unfitting left foot condition coded 5284 and rated 10%, and an unfitting right foot condition, coded 5284 and rated 10%, both IAW VASRD §4.71a.  In the matter of the contended RSD condition, the panel majority recommends no change from the PEB determination as not unfitting.  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 medical separation:  

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

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Dear XXXXXXXXXX:

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.