RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX  	CASE:  PD-2017-01440
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20080915

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E1, Basic Trainee, medically separated for “foot injuries, other” with a disability rating of 20%.  

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 – 20080821 	VARD - 20090324	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Foot Injuries, Other, Left	5284	10%	Bilateral Flat Foot Deformity, Residuals of Stress Fracture	5284-5276	10%	20081118	
Foot Injuries, Other, Right	5284	10%					
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  10% 	

ANALYSIS SUMMARY:  

Foot Injuries.  According to the service treatment record and MEB narrative summary (NARSUM), the CI experienced bilateral foot pain in April 2008 during basic training, with no specific trauma, but after increased running, jumping, marching, and wearing boots, which hurt her feet.  A right foot X-ray series showed a hallux valgus (bunion) deformity with no evidence of a stress fracture.  A bone scan on 11 April 2008 revealed multiple foci of increased ring tracer uptake including the right proximal first and second metatarsal heads and the left proximal first metatarsal head and the posterior aspect of the bilateral calcanei (heel bones) and mid portion of the left calcaneus.  The radiologist’s impression was stress fracture versus reaction.  Crutches along with ibuprofen (a nonsteroidal anti-inflammatory drug), Vitamin D, and calcium carbonate were prescribed.  

On 25 April 2008, foot inserts for each arch were formed, and tramadol (opioid-like medication) was added to the treatment protocol on 28 May 2008.  A bone scan on 10 June 2008 demonstrated stress fractures involving the bases of the first metatarsals and middle cuneiforms (bones) with concurrent stress changes noted throughout the feet and ankles.  At a troop clinic visit on 11 June 2008, the CI had tenderness of the left lateral tarsometatarsal joints, was put on crutches for 10 days, and recommended for 30 days convalescent leave.  Foot X-rays on 30 July 2008 showed sclerosis at both first metatarsal bases consistent with known stress changes.  

During the 31 July 2008 MEB examination (recorded on DD Forms 2807-1 and 2808), 2 months prior to separation, the CI reported foot stress fractures, and the examiner noted bilateral generalized swelling and tenderness.  At a physical therapy visit on 5 August 2008, range of motion (ROM) measurements of the ankles were 11 degrees dorsiflexion on the right and 18 degrees on the left (normal 20), both with pain, and 36 degrees plantar flexion on the right and 40 degrees on the left (normal 45), both with pain.  At a podiatry visit on 6 August 2008, there was swelling of the ankles and feet with excessive pronation of the feet and tenderness of the metatarsals.  

The 6 August 2008 MEB NARSUM examination, 1 month before separation, noted CI complaints of bilateral foot pain.  Physical examination showed a flexible pes planus foot type with tenderness at the base of the first metatarsals bilaterally.  Neurovascular status was intact with dorsal pedis and posterior tibial pulses 2/4.  Dermatological examination revealed a mild amount of edema in the both ankles and feet.  The CI had pain on trying to rise on tiptoe, but was able to perform that motion, and had full ROM of the ankle, subtalar, and metatarsophalangeal joints.  There were no bony prominences, and on stance she had mild pronation.  

At the 18 November 2008 VA Compensation and Pension (C&P) examination, 2 months after separation, the CI reported  pain in both feet aggravated by prolonged standing and walking. Physical examination showed a normal gait and posture, the ability fully squat, and no use of an assistive device for ambulation.  Neither foot showed hindfoot valgus deformity, tightening of the Achilles tendon, malalignment, hammertoe hallux valgus deformity, or calluses in the plantar aspect of the foot.  She had tenderness over the metatarsal areas bilaterally, and pain on manipulation of the right foot.  Examination of the ankles showed no localized tenderness, swelling, deformity, or instability.  Each ankle dorsiflexed to 20 degrees and plantar flexed to 40 degrees, with no pain or loss of motion on repetition.  The diagnosis was healed, bilateral stress fractures with limitations in prolonged standing, walking, and running due to discomfort.  The examiner additionally diagnosed resolved bilateral ankle strain.  There was no additional limitation due to pain, weakness, fatigue, lack of endurance, or incoordination after repetition or flare-ups.  The CI did not require an assistive device and was not provided with any orthotics, custom fitted shoes, or shoe inserts, and there was no evidence of adverse impact on activities of daily living or occupation.  Foot X-rays on 18 November 2008 demonstrated a moderate flatfoot deformity bilaterally, but was otherwise unremarkable.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the right and left foot conditions 10% each, with both coded 5284 (foot injuries, other), citing moderate injury with preserved foot function and ability to walk.  The VA rated the bilateral foot condition 10%, dual coded 5284-5276 (foot injuries, other-flatfoot, acquired), based on the C&P examination, citing the “weight-bearing line was over or medial to the great toe with inward bowing of the tendo achillis (Achilles tendon), and pain on manipulation and use of the feet.”  Members noted that while a bone scan in June 2008 revealed stress fractures in both feet, by November 2008, 2 months after separation, X-rays showed only a moderate bilateral flatfoot deformity, but were otherwise unremarkable.  Furthermore, the CI had a normal gait and used no assistive device during the C&P examination.  Therefore, proximate to separation there was no evidence to support a higher rating for a moderately severe foot injury under code 5284 for either foot.  Additionally, there was no evidence to support a higher rating for either a unilateral or bilateral severe acquired flatfoot condition under code 5276.  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 bilateral foot condition.  

BOARD FINDINGS:  In the matter of the bilateral 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.  

AR20190004443, XXXXXXXXXXXX 

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Dear XXXXXXXXXXXX:

	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.