RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2017-02731
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20060706

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an E5 National Guard, Signal Support Systems Specialist, medically separated for “bilateral heel pain” with a disability rating of 0%.  

CI CONTENTION:  Foot condition continues to worsen and negatively impacts daily activities.  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 - 20060620	VARD - 20070110	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Heel Pain	5022	0%	Stress Fracture Heel And Talus, Left Foot Resolved	5284	10%	20061019	
			Stress Fracture Heel And Talus, Right Foot Resolved	5284	10%	20061019	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  20% 	

ANALYSIS SUMMARY:  

Bilateral Heel Pain.  The PEB combined the right and left foot conditions as a single unfitting condition coded 5022 (periostitis) and rated 0%. The approach by the PEB reflected its judgment that the constellation of conditions was unfitting, and there was no need for separate fitness adjudications or implied adjudication that each condition was separately unfitting.  The panel’s initial charge in this case was therefore directed at determining if the PEB’s approach of 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 right and left foot conditions is presented together, with attendant recommendations regarding separate unfitness, and separate rating if indicated.  

According to the service treatment record and MEB narrative summary (NARSUM), the CI’s bilateral heel pain began in October 2005 during training.  X-rays of the ankles demonstrated mild pre-tibial subcutaneous soft tissue swelling, left great than right.  A bone scan suggested a stress fracture of the posterior aspect of the right calcaneus and a stress fracture of the posterior medial aspect of the left talar dome in the area of the distal tibial epiphysis.  

The 6 April 2006 MEB NARSUM examination, 3 months prior to separation, noted complaints of painful ankles and feet.  Right ankle pain was 7/10 and left ankle pain was 5/10.  Physical examination showed no edema, erythema or cellulitis of either foot or ankle.  Neurovascular status was intact and reflexes were 1+ bilaterally. Bilateral range of motion (ROM) measurements of the ankles were 30 degrees dorsiflexion (normal 20) and 30 degrees plantar flexion (normal 45) without pain.  ROM testing of the subtalar joints showed inversion of 30 degrees bilaterally and eversion of 10 degrees bilaterally with minimal pain on the right and no pain on the left.

At the 19 October 2006 VA Compensation and Pension (C&P) examination, 3 months after separation, the CI reported left greater than right foot pain and could only walk ten to twenty feet or stand for 15 minutes, and he had pain climbing stairs.   Physical examination showed no tenderness or swelling around either ankle.  Dorsiflexion bilaterally was 0-10 degrees and plantar flexion bilaterally was 0-40 degrees, neither with pain or limitation.  Inversion and eversion bilaterally were normal without pain.  There was bilateral tenderness in the posterior/inferior aspect of the heels and tenderness in the middle of the plantar aspect of each foot.  There was pain with extension of the toes.  Neither foot was cold or clammy.  X-rays showed minimal generalized osteopenia (mineral loss in the bones) with pes planus.  There was an old healed un-united fracture of the tibia of the left medial malleolus.  There was no acute fracture, dislocation or significant arthritis on either side.   

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral foot condition 0%, coded 5022, citing no significant loss of joint motion.  The VA rated each foot condition 10%, coded 5284 (foot injuries, other), based on the C&P examination, noting pain.  The panel determined each foot was separately and independently unfitting based on clinical and imaging findings, and a separate rating for each foot is warranted.  The panel noted that the PEB used code 5022, which is rated under the rating requirements of code 5003 (arthritis, degenerative).  While there was no limitation of motion or significant painful motion of the ankles, there was imaging evidence of involvement of both the right foot and left foot, albeit the right foot involved a stress fracture of the calcaneus, while the left foot had a stress fracture at the junction of the talus and distal tibia.  However, Note (2) of code 5003 indicates that the 20% and 10% ratings based on X-ray findings, will not be utilized in rating conditions for codes 5013-5024.  The panel then considered use of code 5284 since the CI did have stress fractures of the foot.  Because of persisting pain in each foot that failed to heal despite months of rehabilitation, a 10% rating for a moderate disability, and no higher, for each foot is reasonable.  The panel also noted the VA imaging findings showed an old un-united fracture of the distal tibia, which could be coded 5262 (tibia and fibula, impairment of: with mild ankle disability) at 10%, and no higher.  However, code 5262 is not applicable for the right foot.  
After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 10% for the right foot condition, coded 5284 and a disability rating of 10% for the left foot condition, coded 5284.  
BOARD FINDINGS:  In the matter of the bilateral foot condition, the panel recommends a disability rating of 10%, coded 5284 IAW VASRD §4.17a for the left foot condition and a disability rating of 10%, coded 5284 IAW VASRD §4.17a for the right foot condition.  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 Heel Pain	5284	10%	
Right Heel Pain	5284	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20170317, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record 

AR20190009188, 

Dear XXXXXXXXXXXXXXXX:

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.