RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXX  	CASE:  PD-2017-01249
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20081126

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Signal Support System Specialist, medically separated for “moderate left foot flatfoot deformity” with a disability rating of 10%.  

CI CONTENTION:  “Continued foot pain, hasn’t gotten better, increasing worse.  Various methods tried and didn’t properly relieve foot pain.” [Sic]   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 - 20080930	VARD - 20090513	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Moderate Left Foot Flatfoot Deformity	5299-5276	10%	Let Foot Plantar Fasciitis w/Fallen Arch, Including Residuals, Stress Fracture 5th Metatarsal	5299-5276	20%	20081015	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  40% 	

ANALYSIS SUMMARY:  

Moderate Left Foot Flatfoot Deformity.  According to the service treatment record and MEB narrative summary (NARSUM), the CI experienced pain along the bottom of his left foot during initial entry training in March 2007, but without specific injury or trauma.  Left foot X-rays on 4 May 2007 showed a nondisplaced stress fracture at the base of the fifth metatarsal (MT).  A bone scan on 14 May 2007 showed increased uptake in the plantar aspect of the calcaneus (consistent with plantar fasciitis), focal uptake over the base of the fifth MT, and general changes of overuse of both ankles and feet.  An electronic foot type analysis performed by physical therapy on 20 September 2007 showed a pes cavus foot (high arch).  Despite profiles and physical therapy the foot pain continued and the CI was given orthotics.  Repeat X-rays on 6 February 2008 showed no evidence of fracture.  Podiatry evaluation in February 2008 diagnosed flat foot deformity, but weight bearing X-rays on 8 February 2008 did not note pes planus.  At a 16 April 2008 follow-up visit, the podiatrist noted no swelling.  On standing there was a well-preserved arch, slightly lower on the left than the right, but no “gross or severe decrease in his medial longitudinal arch.”  The assessment was plantar fasciitis, and the podiatrist opined that the CI did not have any significant flat foot deformity.  

The 21 May 2008 MEB NARSUM examination, 6 months prior to separation, (performed by the treating podiatrist above) noted complaints of foot pain, worse in the morning and aggravated by weight bearing activities.  Physical examination showed genu valgum (knock knee) and no flat foot deformity with non-weight bearing (although the left arch was lower than the right).  There was tenderness of the arch, with calluses under both great toes.  There was moderate to severe pronation of the left heel, and the CI was wearing street shoes for comfort.  

At the 15 October 2008 VA Compensation and Pension (C&P) examination, 1 month before separation, the CI reported progressively worse left foot pain, stiffness and fatigability.  He had moderate daily flare-ups lasting 30 minutes, but did not have additional limitation of motion or other functional impairment during these episodes.  He did not use any assistive device for ambulation, and physical examination showed a normal gait.  The examiner noted tenderness along the sole and a callus under the great toe, but described the arch as normal and slightly lower on the left than right, without deformities.  There was mild pronation noted with standing and walking, but no evidence of flatfoot. 

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left foot condition 10%, analogously coded 5299-5276 (flat foot, acquired), citing the condition was “moderate” with functional loss due to pain.  The VA rated the left foot condition 20%, also coded 5299-5276, based on the C&P examination, citing “symptoms such as marked deformity (pronation, abduction, etc.), pain on manipulation and use, indication of swelling on use and characteristic callosities.”  Members noted that the majority of examinations in the record did not support a diagnosis of flatfoot deformity, however, the CI had genu valgum and a pes cavus foot type with decreased arch height on the left compared to the right, and left plantar foot pain.  The panel agreed that while a 10% rating was analogously supported under code 5276 for moderate pes planus, the threshold to characterize the left foot impairment as severe was not met without evidence of marked deformity or swelling on use.  A 10% rating was also supported alternatively coded as 5278 (clawfoot or pes cavus), but there was no evidence of “all toes tending to dorsiflexion, limitation of dorsiflexion at ankle to right angle, shortened plantar fascia, and marked tenderness under metatarsal heads” for the next higher rating.  The panel also considered analogous code 5399-5310 (group X muscle injury) for plantar fasciitis, but the CI had a normal gait without use of an assistive device, and thus there was no evidence to support a rating higher than 10% for a moderately severe disability.  Members considered other VASRD foot codes, but all were less applicable and not advantageous for rating.  After due deliberation, considering all 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 left foot condition.  

BOARD FINDINGS:  In the matter of the left foot condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  There are no other conditions within the panel’s scope of review for consideration.  Therefore, the panel recommends no modification or re-characterization of the CI’s disability and separation determination.  

AR20190004024, XXXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXXX
:

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found your separation disability rating and your separation from the Army for disability with severance pay to be accurate.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed), and I accept its recommendation.  I regret to inform you that your application to the DoD PDBR is denied.  

	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.