RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  xxxxxxxxxxxxxxxxxxx	CASE:  PD-2017-03862
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20081020

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was a Reserve E2, Trainee, medically separated for “bilateral foot injuries due to stress fractures of the calcaneal, metatarsal, and metatarsophalangeal [MTP],” rated 10% for each side, with a combined disability rating of 20%.   

CI CONTENTION:  His injuries sustained during active duty to both legs and both feet have had a cascading effect on his overall health.”    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 - 20080925	VARD - 20090520 	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Foot Injuries…	5284	20%	Residual, Stress Fractures Right Calcaneal, Metatarsal, MTP, Plantar Fasciitis	5284	10%	20090120	
			Residual, Stress Fractures Left Calcaneal, Metatarsal, MTP, Plantar Fasciitis	5024-5284	10%	20090120	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  20% 	

ANALYSIS SUMMARY:  

Bilateral Foot Injuries.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s bilateral foot and knee conditions began in May 2008 during basic training, without any specific trauma or injury.  In June and July 2008, knee and foot X-rays suggested possible bilateral knee stress fractures, bilateral MTP stress fractures with no evidence of collapse in the tibial plateaus, and normal calcanei (heel bones).  A bone scan on 5 August 2008 showed bilateral MTP stress fractures and bilateral proximal second metatarsal stress reactions/fractures.  At a physical therapy (PT) evaluation on 25 August 2008, right ankle range of motion (ROM) after repetition showed dorsiflexion to 22 degrees (normal 20), with pain beginning at 19 degrees, and  plantar flexion to 59 degrees (normal 45), with pain beginning at 52 degrees.  Left ankle dorsiflexion was to 30 degrees and plantar flexion to 55 degrees, both with painful motion well above the normal ROMs. 

During the 19 August 2008 MEB examination (recorded on DD Forms 2807-1 and 2808), 2 months prior to separation, the CI reported stress fractures to both knees and both feet.  Physical examination revealed tenderness of the bilateral MTP area and anterior tibias, and generalized tenderness of the feet.  The 8 September 2008 MEB NARSUM examination, 1 month before separation, noted the complaints of bilateral foot and knee pain.  The examiner found that the CI walked with a limp and had pain during toe raising, heel walking, and one-legged standing.  He had a rectus foot type with moderate arch height and no excessive pronation or supination.  There was bilateral calcaneal and metatarsal tenderness, but ankle and MTP joint ROM was documented as “full.”  Lower extremity neurovascular findings were intact.  

At a podiatry appointment on 16 December 2008, 2 months after separation, the CI indicated he had been on crutches for 4 months while in the service, but still had to perform duties.  On examination, he had bilateral heel pain with lateral heel squeezes, but ankle ROM was full without pain or crepitus.  Custom prosthetic molded shoes were prescribed.  Bilateral foot X-rays the same day showed no acute fracture, significant degenerative bony spurs/ deformity, or remarkable soft tissue swelling.  At a podiatry follow-up 6 days later, the provider reviewed a foot X-ray series and noted the CI most likely had plantar fasciitis symptomatology. 

At the 20 January 2009 VA Compensation and Pension (C&P) examination, 3 months after separation, the CI had bilateral heel pain and metatarsal discomfort.  The examiner noted a normal gait, and symmetrical feet without redness, swelling, or edema.  There was no abnormal alignment, pes planus, abnormal shoe wear, callous formation, deformity angulation, false motion, shortening, or intra-articular movements.  There was no malunion or nonunion, hammer toes, hallux valgus, or pes cavus and no abnormal weight bearing, varus or valgus, or malalignment of the Achilles tendon.  There was bilateral heel pain with applied pressure, but no abnormal bony prominences or structures.  The diagnoses were: resolved bilateral metatarsal and MTP stress fractures, and bilateral plantar fasciitis with bilateral heel arthralgia.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral foot injuries 20% (10% right and 10% left), coded 5284 (foot injuries, other), citing moderate injury.  The VA rated right and left calcaneal, metatarsal, and MTP stress fracture residuals with plantar fasciitis 10% each, coded 5284, based on the C&P examination, citing moderate symptoms.  Panel members noted that there was no evidence to support a higher rating than 10% for either foot using code 5284 in the absence of a moderately severe or severe disability.  By 2 months after separation, foot X-rays did not show any acute fractures, and by 3 months, the VA examiner noted the stress fractures had resolved, and that the CI had plantar fasciitis and heel arthralgia.  There was no other applicable VASRD foot code which offered a higher 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 bilateral foot condition.  

Contended PEB Conditions:  Left and Right Knee Pain.  The panel’s main charge is to assess the fairness of the PEB lack of determination on whether the contended left and right pain conditions were adjudicated for fitness or unfitness based on the MEB referral to the PEB of bilateral lower extremity stress fractures.  Neither of the conditions were profiled or explicitly implicated in the commander’s statement, and did not fail retention standards.  There was no performance-based evidence from the record that either of the conditions significantly interfered with satisfactory duty performance at separation.  After due deliberation, the panel concluded that neither the left knee condition nor the right knee condition was separately unfitting, so no additional disability rating is recommended for either 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.  In the matter of the contended left and right knee conditions, the panel agrees it cannot recommend them for additional disability rating.  Therefore, the panel recommends no modification or re-characterization of the CI’s disability and separation determination.  

AR20190010861, XXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXX

	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.