RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-04383
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20060103

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Multichannel Transmission Systems Operator, medically separated for “chronic bilateral lower extremity pains” with a disability rating of 0%.   

CI CONTENTION:  Review requested of additional conditions not identified by the Medical Evaluation Board (MEB) and/or Physical Evaluation Board (PEB).  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 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 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 - 20051129	VARD - 20070521	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Bilateral Lower Extremity Pains	5099-5003	0%	Sacroiliitis	5236	10%	20070315	
			Fracture, Right Inferior Pubic Ramus	5299-5252	0%	20070315	
			Bilateral Pes Planus	5276	0%	20070315	
			Left Hip Pain	5299-5252	NSC	20070315	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Chronic Bilateral Lower Extremity Pains.  

Chronic Right Hip Pain (Pelvic Fracture of Ischium and Joint Instability of the Pelvis).  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s pelvis condition began during basic training while running with a full rucksack, but she was not examined until later at advanced individual training.  X-rays of the right hip dated 28 May 2002, ordered for right hip and groin pain since basic training, showed callus bridging a non-displaced stress type fracture of the right ischium/pubic region consistent with a healing stress fracture.  X-rays of the pelvis dated 25 July 2002 demonstrated a transverse fracture of the right inferior pubic ramus with callus formation without complication.  No other inflammatory or arthritic changes were noted.  On 8 December 2003 she complained of recurrent discomfort in the left perineum area.

On 2 June 2004 the CI reported left-sided pain along the inferior portion of the pubic ramus for the past 2 years due to a fracture, but the pain worsened in the prior 3 days.  She had full bilateral hip and knee range of motion (ROM), but was tender at the adductor origin on the left.  The differential diagnosis was tendonitis versus a stress fracture.  At an emergency room visit on 4 August 2004, the CI complained of right hip pain after being in an automobile accident.  X-rays of the pelvis were negative.  A bone scan dated 2 September 2004 showed normal uptake in the pelvis.  A 31 January 2005 pelvis CT scan appeared normal and the sacroiliac joints were normal bilaterally.  X-rays of the pelvis dated 26 June 2005 showed mild spurring of the left symphysis pubis.  The sacroiliac joints and the hips were intact.  There were no active findings.  X-rays of the pelvis erect, with a binder on, demonstrated no significant radiologic abnormality.  

During the 6 September 2005 MEB examination (recorded on DD Forms 2807-1 and 2808), 4 months prior to separation, the CI reported cracking her pelvis during basic training and that her pelvis was out of alignment.  Physical examination revealed decreased strength of the lower extremities, left less than right.  The 26 October 2005 MEB NARSUM examination, 2 months prior to separation, noted the complaint of left hip pain post fracture of the ischium.  There was less than a 2 mm difference in the symphysis pubis with weight bearing, but it was unlikely that a symphysis stabilization procedure would relieve her symptoms.  Physical examination showed tenderness of both hips, more so on the left.  Pain was elicited by the extremes of hip motion with external rotation.  There was no instability in the hips and no weakness.  Motor strength was normal and there was no tenderness on ambulation.  Right hip range of motion (ROM) measurements in degrees were extension 10 (normal 20), flexion 110 (normal 125), adduction 30 (normal 25), abduction 45 (normal), internal rotation 40 and external rotation 40 (normal 45), while ROMs of the left hip were extension 10, flexion 130 , adduction 30, abduction 45, internal rotation 40 , and external rotation 40 .  There was no tenderness of the knees, which had a full ROM of 0-140 degrees bilaterally.  Gait and stance revealed an abnormal slight heel valgus bilaterally.

At a VA clinic examination on 29 April 2006, 4 months after separation, examination of the extremities showed no cyanosis or edema and strength and tone were normal and symmetrical.  At the 15 March 2007 VA Compensation and Pension (C&P) examination, 14 months after separation, the CI reported pain in the lower back after being on her feet greater than 2 hours and pain in the feet.  None of the symptoms were related to her previous inferior pubic ramus fracture.  She was not currently being treated and there were no flare-ups.  The examiner’s diagnosis was a healed right inferior pubic ramus fracture.  Physical examination was normal with a normal gait.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB bundled the pelvic fracture of ischium, joint instability of the pelvis, bilateral pes planus, and bilateral plantar fasciitis conditions under a single disability rating, coded analogously 5099-5003 (degenerative arthritis) and rated 0% with application of the US Army Physical Disability Agency pain policy and AR 635-40 B24.f.,citing slight/occasional pain.  The VA rated the fracture of the right inferior pubic ramus condition 0%, analogously coded 5299-5252 (thigh, limitation of flexion), based on the C&P examination, citing a noncompensable evaluation unless the thigh is limited in flexion to 45 degrees.

The panel first considered if the right hip pain (pelvic fracture of ischium and joint instability of the pelvis) was reasonably justified as separately unfitting.  The panel concluded that the bundled pelvic fracture of ischium and joint instability of the pelvis condition was reasonably supported by the record as separately unfitting from the bilateral pes planus and plantar fasciitis.  Panel members further noted that CI’s main right hip (pelvis) issue was related the fracture of the ischium and the joint instability of the pelvis (referring to the symphysis pubis separation) was a related condition intertwined with the overall right hip disability condition.  The panel then considered its rating recommendation for the separately unfitting pelvic fracture of the ischium manifesting as right hip pain at the time of separation.

The panel noted the CI had painful motion of the right hip at the NARSUM examination with pain at the extremes of external rotation.  Therefore code 5099-5003 offers a 10% rating based on painful motion.  There was no limitation of extension and flexion (codes 5251 and 5252) or thigh impairment (code 5253) nor was there any hip ankylosis (code 5250) or hip, flail joint (code 5254). Femur impairment with malunion and slight hip disability (5299-5255) does not offer a higher rating than 10% assuming the right hip at the time of separation rose to even a slight level since the fracture had healed; and strength was normal. The panel also noted that aalthough there was pain with external rotation, it was bilateral.  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 chronic right hip pain condition, coded 5099-5003.  

Bilateral Foot Pain (Pes Planus and Plantar Fasciitis).  The CI’s bilateral foot pain condition began insidiously in August or September 2004.  The MEPS examination dated 14 January 2002 revealed asymptomatic, mild pes planus.  X-rays of the right ankle, ordered because of pain and ecchymosis of the medial tibia after an ATV accident, were negative.  A bone scan dated 2 September 2004 showed foci of increased uptake in the medial aspect of both calcanei (heels).  X-rays of the feet dated 16 December 2004 demonstrated flattening of the plantar arches consistent with the presence of pes planus.  There was an accessory navicular bone also present bilaterally.  During the 6 September 2005 MEB examination (recorded on DD Forms 2807-1 and 2808), 4 months prior to separation, the CI reported both arches fell during a ruck march.  Physical examination revealed symptomatic pes planus.  

The 12 October 2005 commander’s statement noted the CI received inserts for her feet in October 2004 and had been wearing them since that time.  An L3 profile was issued on 24 October 2004 for bilateral pes planus and plantar fasciitis.  The MEB NARSUM examination2 weeks later, noted the complaint of bilateral foot pain, which increased with impact activities, but her shoe inserts reportedly did not provide sustained relief.  Physical examination of the feet showed bilateral flat feet with standing.  She did form an arch when sitting and had tight heel cords with dorsiflexion to neutral with the knees extended, but increased to the aforementioned dorsiflexion values when the knees were flexed.  She was able to do single limb toe raises, and there were no discrete points of tenderness on the plantar fascia.  Gait and stance revealed an abnormal slight heel valgus bilaterally.  A medical statement dated 22 November 2005 indicated plantar fasciitis was a purely clinical diagnosis and could not be made or refuted by X-rays.  

At the 15 March 2007 VA Compensation and Pension (C&P) examination, 14 months after separation, the CI reported bilateral pes planus and a history of stress fractures diagnosed in September 2004 and complained of pain in both feet with standing and walking, but not at rest.  She used inserts in her shoes and there was no effect on her occupation, although weight bearing increased her foot pain.  Physical examination showed no objective findings of painful motion in the midfoot, hindfoot, or forefoot.  There was no edema, no instability, and no tenderness, and she had a normal gait.  Functional limitation with standing was 2 hours and with walking was very short distances.  She had normal alignment of her left Achilles tendon and slight valgus alignment of the right Achilles tendon.  There was no pain with manipulation.

The panel directed attention to its rating recommendation based on the above evidence.As noted above, the PEB bundled the pelvic fracture of ischium, joint instability of the pelvis, bilateral pes planus, and bilateral plantar fasciitis conditions under a single disability rating, coded analogously 5099-5003 (degenerative arthritis) and rated 0% with application of the US Army Physical Disability Agency pain policy and AR 635-40 B24.f., The VA rated the bilateral pes planus condition 0%, coded 5276 (flatfoot, acquired), based on the C&P examination, citing the condition existed prior to military service and was permanently worsened as a result of service, and mild symptoms relieved by built-up shoe or arch support(s). 

The panel first considered if the bilateral foot pain (pes planus and plantar fasciitis) was reasonably justified as separately unfitting.  The panel concluded that the bundled bilateral foot pain condition was reasonably supported by the record as separately unfitting from the right hip pain.  Panel members further noted that CI’s bilateral foot pain consisted of two conditions, pes planus that existed prior to enlistment and plantar fasciitis.  The STR provided very limited information about the bilateral plantar fasciitis other than indicating shoe inserts were prescribed, which reportedly did not provide sustained relief.  In the absence of other documented podiatric, physical therapy, or orthopedic interventions, the panel could not determine the severity of the plantar fasciitis bilaterally or of either unbundled individual foot plantar fasciitis to be more than slight.  The bilateral pes planus was service aggravated based on the transition from asymptomatic at the military entrance processing station examination to symptomatic at the MEB examination.  The panel then considered its rating recommendation for the separately unfitting bilateral foot pain consisting of bilateral pes planus and plantar fasciitis.

As noted there was insufficient evidence to support a rating for the bilateral plantar fasciitis or plantar fasciitis of either foot higher than slight based upon the absence of discrete points of tenderness at the NARSUM examination.  Therefore, a 0% rating for each foot is the maximum that can be recommended using code 5399-5310 (Group X: plantar aponeurosis).  The bilateral pes planus, likewise lacked sufficient information or findings to warrant more than a 0% rating for mild symptoms relieved by built up shoe or arch supports using code 5276.  A higher rating of 10% is not warranted for moderate symptoms bilaterally or unilaterally in the absence of the weight-bearing line over or medial to the great toe, inward bowing of the Achilles tendon, and pain on manipulation, albeit she did report some pain on the use of the feet with impact activities.  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 0% for the bilateral foot pain condition, coded 5310-5276.  

BOARD FINDINGS:  In the matter of the right hip pain condition, the panel recommends a disability rating of 10%, coded 5099-5003 IAW VASRD §4.71a.  In the matter of the bilateral foot pain condition, the panel recommends a disability rating of 0%, coded 5310-5276 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	
Right Hip Pain	5099-5003	10%	
Bilateral Foot Pain	5310-5276	0%	
COMBINED	10%	

The following documentary evidence was considered:

AR20200000205

Dear XXXXXXXXXXXX

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.