RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-03788
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20070911

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E3, Nodal Network Systems Operator-Maintainer, medically separated for “bilateral heel pain” and “stress fracture right medial tibial plateau,” rated 10% and 0%, respectively, with a combined disability rating of 10%.  

CI CONTENTION:  Review of all conditions requested.  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 - 20070821	VARD - 20080124	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Heel Pain…	5099-5003	10%	Left Calcaneal Heel Stress Fracture	5311	0%	20071115	
			Right Calcaneal Stress Fracture	5311	0%		
Stress Fracture Right Medial Tibial Plateau	5099-5022	0%	Stress Fracture, Right Medial Tibial Plateau	5311-5022	10%		
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Bilateral Heel Pain.  The PEB combined the left and right heel pain under a single disability rating, analogously coded 5099-5003 (degenerative arthritis (hypertrophic or osteoarthritis)) and rated 10% with application of the US Army Physical Disability Agency pain policy and AR 635-40 B24.f.  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 noted that “bundling,” the combining of two or more major joints, may be permissible under the VASRD 5003 rating requirements, and that this approach does not compromise the VASRD §4.7 directive to choose the higher of two valid ratings.  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 (STR) and MEB narrative summary (NARSUM), the CI’s bilateral heel pain began in June 2007 with no specific injury noted.  His heels were treated over 12 weeks and inserts did not relieve his pain.  A bone scan on 17 April 2007 demonstrated a possible stress change injury involving the ankles.  Bilateral heel X-rays on 7 June 2007 showed an area of sclerosis of the calcaneal area without obvious fractures or healing stress fractures.  

During the 19 July 2007 MEB examination (recorded on DD Forms 2807-1 and 2808), 2 months prior to separation, showed bilateral, moderate pes planus with heel tenderness.  The MEB NARSUM examination a week later noted complaints of bilateral heel pain. Physical examination showed tenderness over the calcaneus (heel) bilaterally.  

At the 15 November 2007 VA Compensation and Pension (C&P) examination, 2 months after separation, the CI reported daily, bilateral heel pain especially with prolonged standing.  He wore shoe inserts.  Physical examination showed a well-coordinated gait and tenderness in both heels.  

The panel directed attention to its rating recommendation based on the above evidence.  As noted above, the PEB bundled the left and right heel pain and applied a single 10% rating coded 5003.  The VA rated the left and right heel conditions 0% each, coded 5311 (Group XI. function), based on the STR and C&P examinations, citing “symptoms do not meet the criteria for a 10 percent evaluation which requires objective evidence of moderate muscle disability.”  

The panel first considered if the bilateral heel pain condition met the panel’s threshold for separate rating (as elaborated above).   In this case, the feet were considered to fail retention standards and were profiled and implicated by the NARSUM.  Panel members agreed that each foot could be reasonably justified as separately unfitting.  The panel then considered its rating recommendation. The evidence did not support separate ratings for moderate foot injury (5284).  Although there was pain with use, there was evidence of pain on manipulation to support a 10% rating analogous to moderate pes planus (5276) or analogous to metatarsalgia (5279). After due deliberation, and considering all the evidence, the panel concluded there was insufficient cause to recommend a change in the PEB adjudication for the bundled heel pain.  

Stress Fracture Right Medial Tibial Plateau.  According to the STR and MEB NARSUM, the CI had a right femur fracture and was treated with a right femur open reduction/internal fixation and intramedullary nail surgery in September 2002, prior to military service.  After entering military service, he began having stress fractures of the proximal tibia in March 2007.  X-rays on 16 April 2007 showed a normal right knee.  A bone scan on 17 April 2007 showing changes consistent with stress fractures on the right medial tibial plateau.  

The 25 July 2007 MEB NARSUM examination, noted complaints of right knee pain.  Physical examination showed tenderness, an antalgic gait, and pain with motion. Range of motion (ROM) showed flexion of 135 degrees (normal 145) and normal extension at 0 degrees.  

At the VA C&P examination, the CI reported persistent right knee pain with walking and prolonged standing. Physical examination showed tenderness and pain at the end of motion.  Flexion was 115 degrees and extension was to 0.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the right medial tibial condition 0%, analogously coded 5099-5022 (periostitis), citing stable knee with full ROM.  The VA rated the right medial tibial condition 10%, dual coded 5311-5022 (Group XI. Function - periostitis), based on the STR and C&P examinations, citing painful or limited motion of a major joint or group of minor joints.  

There was no limitation of motion which supported a rating under the diagnostic codes for limitation of flexion or extension (5260, 5261). However, there was evidence of painful motion with functional loss supporting a 10% rating (based on §§4.59, 4.40 and 4.45). There was no history or evidence of dislocated meniscus or loose body causing frequent locking with recurrent effusions (5258), to support a rating under that code. There was no fracture, nonunion or malunion of the femur or tibia to support consideration under the respective codes for knee impairment related to long bone conditions (5255, 5262).  There was therefore no VASRD §4.71a rating higher than the 10% adjudicated by the PEB under any applicable code. 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 medial tibial condition, coded 5099-5022.  

BOARD FINDINGS:  In the matter of the bilateral heel pain, the panel recommends each joint as unfitting and no change in the PEB adjudication.  In the matter of the right medial tibial condition, the panel recommends a disability rating of 10%, coded 5099-5022 IAW VASRD §4.71a.  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	
Bilateral Heel Pain	5099-5003	10%	
Stress Fracture Right Medial Tibial Plateau	5099-5022	10%	
COMBINED	20%	

The following documentary evidence was considered:

AR20190008470, XXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX

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.