RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2017-05846
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20070307

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Food Service Specialist, medically separated for “metatarsalgia with bilateral foot pain” with a disability rating of 10%.  

CI CONTENTION:  Review all conditions.  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 - 20061214	VARD - 20070719	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Metatarsalgia, w/ Bilateral Foot Pain	5279	10%	Metatarsalgia, Left Foot w/ Pes Planus and Calcaneal Spur 	5279-5284	10%	20070628	
			Metatarsalgia, Right Foot w/ Pes Planus 	5279-5284	0%	20070628	
Bilateral Knee Pain	Not Unfitting	Patellofemoral Pain Syndrome, Right Knee	5261	10%	20070628	
Headaches Including Migraine Headaches	Not Unfitting	Migraines	8100	30%	20070628	
Bilateral Shoulder Pain	Not Unfitting	No VA Placement	
Irregular Menstrual Cycles and Infertility	Not Unfitting	No VA Placement	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  60% 	

ANALYSIS SUMMARY:  

Bilateral Foot Pain.  The PEB combined the right and left foot conditions as a single unfitting condition coded 5279 (metatarsalgia, anterior (Morton’s disease), unilateral, or bilateral) and rated 10%.  The 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 also noted that “bundling,” the combining of unilateral, or bilateral metatarsalgia is permissible under the VASRD 5279 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 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 pain conditions are presented 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 foot condition began in July 2003 while in basic training.  She was treated and evaluated by podiatry and neurology, but all conservative treatment was unsuccessful.  The 2 November 2006 MEB NARSUM examination, 4 months prior to separation, noted complaints of foot pain with orthotics required for both feet and a night splint for the left foot.  Physical examination showed normal range of motion (ROM), arches, and color, with no erythema or swelling.  There was tenderness under the calcaneus and over the entire arch of each foot as well as along the metatarsals.  

At the 28 June 2007 VA Compensation and Pension (C&P) examination, 4 months after separation, the CI reported daily chronic foot pain, weakness, stiffness and swelling.  Pain was rated at 4/10 and increased to 7/10 with prolonged standing.  Physical examination showed a inversion of both feet “reduced at 20 out of 30 degrees” due to pain; and eversion of both feet “reduced at 10 degrees out of 20 degrees” due to pain.  The arches were flattened bilaterally, but she had normal gait with no evidence of functional limitations on standing or walking.  

Panel member first agreed that the preponderance of evidence did support a conclusion that the functional impairment from the bilateral foot pain was integral to the CI’s inability to perform her duties.  However, it was clear that the diagnosis of metatarsalgia was appropriately coded as a bilateral condition and accordingly the panel cannot recommend separate ratings.

The panel directed attention to its rating recommendation based on the above evidence.  As noted above, the PEB rated the bilateral foot condition 10%, analogously coded 5279, citing functional limitations in maintaining the appropriate level of mobility.  The VA also rated the bilateral foot condition 10%, analogously coded 5279-5284 (foot injuries, other), based on the C&P examination, citing moderate symptoms.  Panel member agreed there was evidence of metatarsalgia to justify a 10% rating under code 5279 for the combined bilateral condition.  There was no foot weakness (5277), evidence of claw foot (5278) or acquired flatfoot (5276); and no tarsal or metatarsal bone malunion or nonunion (5283), or other foot injuries (5284) to support a moderately severe rating under the respective diagnostic codes.  There was also no evidence of moderately severe ongoing foot pain that could be analogously coded under 5399-5310 (Group X. Function: Movements of forefoot and toes) for a 10% rating.  Thus, there was no other VASRD §4.71a rating higher than that adjudicated by the PEB under any applicable code for either foot.  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded that there was insufficient cause to recommend a change in the PEB adjudication for the bilateral foot pain.  

Contended PEB Conditions:  Bilateral Knee Pain, Headaches Including Migraine Headaches, Bilateral Shoulder Pain, and Irregular Menstrual Cycles and Infertility.  The panel’s main charge is to assess the fairness of the PEB determination that the contended conditions were not unfitting.  The conditions were not profiled or implicated in the commander’s statement, and did not fail retention standards.  There was no performance-based evidence from the record that any of the conditions significantly interfered with satisfactory duty performance at separation.  After due deliberation, the panel concluded there was insufficient cause to recommend a change in the PEB fitness determination for any of the contended conditions, so no additional disability ratings are recommended.  

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 bilateral knee pain, headaches including migraine headaches, bilateral shoulder pain and irregular menstrual cycles and infertility, the panel recommends no change from the PEB determinations as not unfitting.  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.  

ARXXXXXXXXXXX, XXXXXXXXXXXXXXX

Dear XXXXXXXXXXXX:

	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