RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-02566
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20080906

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E1, Infantryman, medically separated for “bilateral pes cavus deformity” with a disability rating of 10%.   

CI CONTENTION:  No specific contention was made.  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 - 20080709	VARD - 20090409	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Pes Cavus Deformity 	5299-5278-5279	10%	Bilateral Pes Cavus	5278	10%	20090302	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  50%	

ANALYSIS SUMMARY:  

Pes Cavus Deformity.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI was noted to have asymptomatic pes cavus (high arches) on his service entry physical (11 March 2004).  He subsequently developed foot pain concurrently with a deployment to Iraq (August 2005 - August 2006).  Although all of the provider entries in the available STR refer only to right foot pain, bilateral pain was addressed in the NARSUM and forwarded to the PEB.  The diagnosis was metatarsalgia associated with pes cavus, and positive examination findings were confined to plantar tenderness.  Imaging (bilateral X-rays and right foot MRI) revealed no significant pathology other than pes cavus.  There were no surgical indications and the pain did not respond sufficiently to orthotics and conservative measures.  There was no documentation in STR provider entries of decreased range of motion (ROM) of the ankle or foot, ankle complaints, gait disturbance, foot deformity (other than pes cavus) or additional VASRD-ratable findings.   

The 29 October 2007 MEB NARSUM (podiatry) examination, 10 months prior to separation, documented metatarsalgia with pain in the balls and arches of his bilateral feet.  He could no longer stand for long periods of time and had pain when running, rucking or performing other high impact, sustained or weight-bearing activities.  The physical examination recorded an antalgic gait, “severe” pes cavus deformity and calluses over the balls and heels of both feet without note of tenderness.  There was also no note of ankle or foot ROM limitation, painful motion or other positive findings.  

The 2 March 2009 VA Compensation and Pension (C&P) examination, 6 months after separation, documented persistent foot pain, confined to the arches, that limited standing to two hours and running to two miles.  The physical examination recorded a normal gait, high arches without callosities or evidence of abnormal weight bearing, “no tenderness to manipulation of the forefoot or hind foot” and normal foot alignment.  As in the NARSUM, there was no note of ankle or foot ROM limitation, painful motion or other positive findings.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral foot condition 10%, analogously dual coded 5299-5278-5279 (pes cavus causing metatarsalgia).  The VA also rated the bilateral foot condition 10%, coded 5278 (pes cavus), based on the C&P examination, citing “some evidence of metatarsalgia pain.”

The panel first considered whether separate ratings for each foot was justified in lieu of the combined bilateral rating as adjudicated by the PEB and VA.  In order to recommend separate ratings for conditions consolidated under a single rating by the PEB, the panel must assess whether each condition is reasonably justified as separately unfitting, although it is considered to be so unless there is a preponderance of evidence to the contrary.  That notwithstanding, bilateral rating is offered under various foot codes; and, unless it violates VASRD §4.7 (higher of two evaluations), a bilateral rating under an applicable code is appropriate regardless of separate fitness considerations.

Both of the above codes 5278 and 5279 are clinically applicable (and fairly specific) for this case and each offers bilateral rating options (elaborated below).  The panel agreed that no alternative foot or joint codes available in VASRD §4.71a were applicable (even analogously) for superseding codes 5278 or 5279.  There was no ankle involvement or ROM limitation (code 5271), no evidence of diagnosis or deformity ratable under more specific foot codes (5276, 5277, 5280, 5382, 5283), and no history of trauma to justify separate ratings under code 5284 (foot injuries, other).  The panel thus considered the appropriate rating under code 5278 or 5279.  

The 10% criteria for code 5278, unilateral or bilateral, are fixed dorsiflexion of the great toe, limitation of ankle ROM or tenderness of the metatarsal head.  Only the latter was supported by the evidence (STR provider notes, equivocally in NARSUM).  Any higher rating under code 5278 requires fixed dorsiflexion of all toes, inability to dorsiflex the ankle beyond neutral, shortened plantar fascia and marked tenderness of all metatarsal heads (none of which are in evidence).  Code 5279 offers a maximum 10% rating for unilateral or bilateral metatarsalgia.  Thus, 10% is the maximum supported rating under either code; and, the panel agreed that separate ratings under each code would constitute pyramiding (VASRD §4.14).  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 there be no modification or re-characterization of the CI’s disability and separation determination.  

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20170309, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record 

AR20190006082, XXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX:

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.