RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-04724
BRANCH OF SERVICE:  ARMY	SEPARATION DATE:  20050118

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Track Vehicle Repairer and Multiple Launch Rocket System Repairer, medically separated for “chronic bilateral foot pain” with a disability rating of 10%.

CI CONTENTION:  The CI contends a rating for the left foot and back.  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 - 20041217	VARD - 20051103	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Bilateral Foot Pain due to Tibial Sesamoiditis	5299-5003	10%	Right Foot Plantar Fasciitis	5299-5279	0%	20050411	
			Right Great Toe Sesamoiditis	5099-5003	10%		
			Left Foot Plantar Fasciitis	5299-5279	0%		
			Left Great Toe Sesamoiditis	5099-5003	10%		
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:

Bilateral Foot Pain due to Tibial Sesamoiditis.  The PEB combined the right and left foot conditions under a single disability rating, coded analogously to 5003 and rated 10% with application of the US Army Physical Disability Agency pain policy.  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.  The evidence for the left and right foot conditions is presented below, with attendant recommendations regarding separate unfitness, and separate rating if indicated. 

According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s bilateral foot condition began insidiously years prior.  Foot pain was aggravated by prolonged standing and lifting substantial weight.  The foot pain continued despite conservative treatment.  

The 29 September 2004 MEB NARSUM examination, 4 months prior to separation, noted complaints of pain on the balls of both feet just behind the big toes.  Physical examination showed a normal gait and tenderness to palpation directly over the tibial sesamoids (small bones on the tibial and fibular aspects of the metatarsophalangeal (MTP) joint) of both feet.  There was normal foot color, without swelling and normal lower extremity strength and sensation.  Ankle, subtalar, mid-tarsal and first MTP joint range of motion (ROM) was normal bilaterally.  

At the 5 May 2009 VA Compensation and Pension (C&P) general evaluation, 3 months after separation, the CI reported a history of sesamoiditis since the late 1980’s.  The examiner noted the CI had started a new job 3 weeks earlier that involved being on his feet all day and carrying objects of up to 50 pounds.  He reported constant bilateral foot pain that improved with rest and an aspirin a day.  The examiner recorded the CI “could walk and stand as long as he has to.”  The CI also reported a history of plantar fasciitis bilaterally, with no flare-ups since 1997.  Physical examination showed a normal gait.  Examination of the ankles was normal with full, painless ROM.  Ankle X-rays were unremarkable.  The examination of the bilateral feet showed high arches that caused increased pressure to the sesamoids of the toe when walking or standing.  There was no hallux valgus, hammertoes, callosities or clawfoot.  The second, third, fourth, and fifth toes were unremarkable.  The Achilles tendons were straight.  There was no malalignment of the foot.  There was painful motion of the great toes on maximal passive ROM.  The examiner stated the pain did not significantly influence the ROM.  Heel and toe raises were painful bilaterally.  The examiner also noted pain of the plantar fascia “momentarily” following great toe ROM testing.  Foot X-rays showed a bipartite medial sesamoid on the right but were otherwise unremarkable.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral foot condition 10%, analogously coded 5003 (arthritis, degenerative).  The VA rated the right and left foot conditions 10% each, analogously coded 5003 (arthritis, degenerative), citing limited motion of a group of minor joints.  The VA also rated the right and left foot conditions 0% each, analogously coded 5279 (metatarsalgia) based on the C&P evaluation, citing a non-compensable examination.

The panel first considered if the right and left foot conditions, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  Sesamoiditis of both feet was profiled and judged to fail retention standards.  The commander’s statement and other STR evidence did not provide any information which would permit the panel to discriminate the performance limitations attributable to either foot over the other.  Since undue speculation would be required to conclude that impairment from either foot would not have unacceptably interfered with the performance of military duties, members agreed that each foot was reasonably justified as separately unfitting.  Since the relevant evidence for rating was identical for each foot, the panel next considered the rating of the left and right foot conditions together.  

There was evidence of tenderness and pain with ROM of the bilateral great toes to support a 10% rating for metatarsalgia (5279), which is a 10% rating whether unilateral of bilateral.  There was no evidence of flatfoot (5276), weak foot (5277), claw foot, (5278) or malunion/nonunion of the tarsal or metatarsal bone (5283) for higher ratings under these codes.  There was no evidence of injury of either foot (5284) to warrant a rating under that code.  There was no evidence of painful limited motion of a group of minor joints to warrant an individual 10% rating under 5003 or related codes.  According to the VASRD, a minor joint of the lower extremity would be the interphalangeal joint, metatarsophalangeal joint or transverse tarsal joint and a combination of two or more minor joints in the lower extremities also constitutes a group of minor joints.  There was only evidence of painful motion of the great toe joints with passive ROM, not with active ROM or even resisted active ROM, and there was no evidence of painful, limited motion of the interphalangeal joints or transverse tarsal joints.  Therefore, after having unbundled the feet, the panel arrived at a recommendation for a combined 10% rating and no higher for the feet.  The panel noted that the PEB’s reliance on the pain policy was not detrimental to arriving at the highest rating and therefore no change to the PEB’s combined adjudication or coding choice is recommended.  After due deliberation, considering all of 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 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 20170609, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record

AR20180006725 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.

Sincerely,					      
Enclosure