RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW NAME: XXXXXXXXXXXXXXX CASE: PD1200737 BRANCH OF SERVICE: ARMY BOARD DATE: 20130315 SEPARATION DATE: 20030707 SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was a National Guard PV2/E-2 (62J/General Construction Equipment Operator) medically separated for a bilateral condition. He developed bilateral chronic heel pain, associated with military footwear, in 1998; and, after a protracted trial of conservative and surgical podiatric interventions, the condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS) or satisfy physical fitness standards. He was issued a permanent L4 profile and referred for a Medical Evaluation Board (MEB). The condition, characterized as “chronic foot pain, bilateral”, was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. No other conditions were submitted by the MEB. The Informal PEB (IPEB) adjudicated the bilateral MEB submission as separately unfitting right and left foot conditions (with surgical residuals elaborated); rated 10% each, citing criteria of the Veteran’s Affairs Schedule for Rating Disabilities (VASRD). The CI made no appeals, and was medically separated with a 20% combined disability rating. CI CONTENTION: “I have had 5 surgeries on my feet, with no positive results. All doctors I have seen since then have stated that there is nothing else they can do at this time other than give me medication for the pain. I will be on medication for the remainder of my life. I am now experiencing joint deterioration in my knees, hips and ankles due to the way I walk because of my feet. It is painful to be on my feet but I endure the pain and work so that I can help support my family.” SCOPE OF REVIEW: The Board’s scope of review is defined in DoDI 6040.44, Enclosure 3, paragraph 5.e.(2). It is limited to those conditions determined by the PEB to be unfitting for continued military service and those conditions identified but not determined to be unfitting by the PEB when specifically requested by the CI. The ratings for the unfitting foot (encompassing ankle) conditions are addressed below. The associated knee and hip conditions, as per the contention, were not identified by the PEB; and, thus are not within the DoDI 6040.44 defined purview of the Board. Those, and any other conditions or contention not requested in this application, remain eligible for future consideration by the Army Board for Correction of Military Records. The Board acknowledges the CI’s information regarding the significant impairment with which his service-connected conditions continue to burden him; but, must emphasize that the Disability Evaluation System has neither the role nor the authority to compensate members for anticipated future severity or potential complications of conditions resulting in medical separation. That role and authority is granted by Congress to the Department of Veterans Affairs, operating under a different set of laws. RATING COMPARISON: Service IPEB – Dated 20030520 VA – Service Treatment Records (STR) and Civilian Records* Condition Code Rating Condition Code Rating Exam Bilateral Foot Pain, Surgical Residuals 8799-8725 10% Bilateral Tarsal Tunnel Syndrome 8525 NSC STR/Civilian 10% No Additional MEB/PEB Entries Other x 1 – Also Not Service Connected (NSC) STR/Civilian Combined: 20% Combined: NSC *Derived from VA Rating Decision (VARD) dated 20040930. No VA exam performed since the VA did not service connect the CI’s two disability claims. VA also did not have access to National Guard Service Treatment Records, and utilized private medical records and available STR evidence. Subsequent VA Rating Determination following receipt of STRs was unchanged. ANALYSIS SUMMARY: The PEB adjudicated each foot as service-incurred or permanantely aggravated, unfitting and rated at 10% each with no deduction for any pre-existing condition. Entry exams documented no foot pathology or disability. This Board will therefore focus only on the disability rating of each foot at the date of separation and not causation or service- connection. Bilateral Feet Pain Condition. The narrative summary (NARSUM) and MEB from the attending surgeon 2 months prior to separation was followed by a podiatry NARSUM and detailed the CI’s history as summarized above. Right foot surgey included a plantar fascia release and two tarsal tunnel releases. Left foot surgery was a tarsal tunnel release. The CI was on narcotic pain medication and had pain “rated as a constant marked pain by the AMA guidelines.” Exam documented an antalgic gait with bilateral ankle range-of-motion (ROM) of dorsiflexion 10 degrees (normal 20 degrees), plantar flexion 40 degrees (normal 45 degrees), eversion of 5 degrees and inversion of 10 degrees. Sensation was intact and there were bilateral posteromedial curvilinear scars that were hypersensitive. The diagnosis was bilateral chronic heel pain. The podiatry exam was proximate to the official NARSUM and exam indicated “curvilinear cicatrix (scar) with notable scar tissue and hyperesthesia at proximal aspect of medial malleolus front/tarsal canal. The area is exquisitely sensitive to touch bilaterally. No range-of-motion loss in the ankle joint or subtalar joint is noted. There is an antalgic gait and the patient supinates in a static stance position.” The examiner stated “Currently the patient works as a manufacturing operator. He is able to do his civilian job.” Diagnosis was “Bilateral, chronic recurrent heel pain. Severity - severe.” Profile restriction was no running, jumping, marching or long-standing over 2 minutes. No Army Physical Fitness Test (APFT); footgear of comfort (no military footgear). There was no VA Compensation and Pension (C&P) exam performed. The Board directs attention to its rating recommendation based on the above evidence. The VA did not service-connect the CI’s foot conditions in either their initial VARD withour access to the STRs, or in remote post-separation VARD after service treatment records were provided. The PEB rated each foot at 10% coded 8799-8725 for moderate neuralgia of the posterior tibial nerve. IAW VASRD §4.124 (neuralgia, cranial or peripheral) moderate is the highest rating possible. The tarsal tunnel is correctly coded under the posterior tibial nerve, and there was insufficient evidence that the next higher nerve (internal popliteal nerve [tibial]) was materially involved. The Board considered if neuritis (IAW VASRD §4.123) was more appropriate than neuralgia; however, there were no organic changes and rating maximum would still be that for moderate (10%) and coding change would offer no benefit. There was no documented ankle joint pathology and no route to dual coding either foot given the provisions of VASRD §4.14 (avoidance of pyramiding). The Board considered if the CI’s underlying pathology and surgeries for the disability of the right foot (plantar fascia release and two tarsal tunnel releases) would rate higher than the moderate (10%) under code 5284 (Foot injuries, other). The Board deliberated on the 20% criteria of “Moderately severe” combinding the nerve condition as neuritis and the plantar fascia surgery residuals under analogous coding of 8625-5284 IAW VASRD 4.71a. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudications for the bilateral foot pain condition as 10% for each foot. The Board concluded therefore that this condition could not be recommended for additional disability rating. BOARD FINDINGS: IAW DoDI 6040.44, provisions of DoD or Military Department regulations or guidelines relied upon by the PEB will not be considered by the Board to the extent they were inconsistent with the VASRD in effect at the time of the adjudication. The Board did not surmise from the record or PEB ruling in this case that any prerogatives outside the VASRD were exercised. In the matter of the bilateral foot pain condition and IAW VASRD §4.124a, the Board unanimously recommends no change in the PEB’s adjudications as 10% for each foot. There were no other conditions within the Board’s scope of review for consideration. RECOMMENDATION: The Board, therefore, recommends that there be no recharacterization of the CI’s disability and separation determination, as follows: UNFITTING CONDITION VASRD CODE RATING Bilateral Foot Pain Left 8799-8725 10% Right 8799-8725 10% COMBINED (w/ BLF) 20% The following documentary evidence was considered: Exhibit A. DD Form 294, dated 20120609, w/atchs Exhibit B. Service Treatment Record Exhibit C. Department of Veterans’ Affairs Treatment Record XXXXXXXXXXXXXXXXXXX, DAF Acting Director Physical Disability Board of Review SFMR-RB MEMORANDUM FOR Commander, US Army Physical Disability Agency (TAPD-ZB / XXXXXXXXX), 2900 Crystal Drive, Suite 300, Arlington, VA 22202-3557 SUBJECT: Department of Defense Physical Disability Board of Review Recommendation for XXXXXXXXXXXXXXXX, AR20130005529 (PD201200737) I have reviewed the enclosed Department of Defense Physical Disability Board of Review (DoD PDBR) recommendation and record of proceedings pertaining to the subject individual. Under the authority of Title 10, United States Code, section 1554a, I accept the Board’s recommendation and hereby deny the individual’s application. This decision is final. The individual concerned, counsel (if any), and any Members of Congress who have shown interest in this application have been notified of this decision by mail. BY ORDER OF THE SECRETARY OF THE ARMY: Encl XXXXXXXXXXXXXXXXX Deputy Assistant Secretary (Army Review Boards)