RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW NAME: XXXXXXXXXXXXXXX BRANCH OF SERVICE: ARMY CASE NUMBER: PD1200918 SEPARATION DATE: 20030610 BOARD DATE: 20130131 SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SPC/E-4 (88M/Motor Transport Operator), medically separated for painful feet (metatarsalgia) condition. The CI did not respond adequately to conservative treatment and was unable to meet the physical requirements of her Military Occupational Specialty (MOS) or meet physical fitness standards. She was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB). Metatarsalgia was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. Five other conditions, as identified in the rating chart below, were also forwarded on the MEB submission as meeting retention standards. The PEB adjudicated the painful feet condition as unfitting, rated 0%, with application of the US Army Physical Disability Agency (USAPDA) pain policy. The remaining conditions were determined to be not unfitting and therefore not ratable. The CI made no appeals, and was medically separated with a 0% disability rating. CI CONTENTION: “As I get older my disabilities are worsening. It is difficult to walk long distances, every time I stand for periods longer than 15 minutes my feet swells up it is very difficult to find shoes that fit, I always have to buy a size bigger. I can’t climb steps, there are frequents chest pains, I get light headed or dizzy and my knees are always buckling, my hand and feet stays swollen and they hurt. When I walk I have to turn my foot in, in order to minimize the pain. What I can’t figure out is that they still haven’t told me what is wrong with me. I think that I was misdiagnose. I am not the same person.” SCOPE OF REVIEW: The Board wishes to clarify that the scope of its review as defined in DoDI 6040.44, Enclosure 3, paragraph 5.e. (2) is limited to those conditions which were determined by the PEB to be specifically unfitting for continued military service; or, when requested by the CI, those condition(s) “identified but not determined to be unfitting by the PEB.” The ratings for unfitting conditions will be reviewed in all cases. The mild carpal tunnel and idiopathic edema conditions and the unfitting painful feet condition, to include the pes cavus, meet the criteria prescribed in DoDI 6040.44 for Board purview, and are accordingly addressed below. The other requested condition, bilateral knee condition, is not within the Board’s purview. Any conditions or contention not requested in this application, or otherwise outside the Board’s defined scope of review, remain eligible for future consideration by the Army Board for Correction of Military Records. RATING COMPARISON: Service IPEB – Dated 20030219 VA (4 Mos. Post-Separation) – All Effective Date 20030610 Condition Code Rating Condition Code Rating Exam Painful feet/metatarsalgia 5099-5003 0% B Metatarsalgia w/pes cavus 5279-5278 10% 20031004 Pes Cavus Not Unfitting Mild Carpal Tunnel Not Unfitting L Wrist, Carpal Tunnel 8515 10% 20030930 R Wrist, Carpal Tunnel 8515 10% 20030930 Mild L5 Nerve Root Paresthesias Not Unfitting L5 Nerve Paresthsias 5299-5294 NSC 20030930 Idiopathic Edema Not Unfitting Idiopathic Edema 7199-7121 NSC 20030930 Pregnancy Not Unfitting NO VA ENTRY .No Additional MEB/PEB Entries. R Knee Strain 5099-5024 10% 20031004 L Knee Strain 5099-5024 10% 20031004 0% X # / Not Service-Connected x 5 20030930 Combined: 0% Combined: 50% ANALYSIS SUMMARY: The Board acknowledges the sentiment expressed in the CI’s application regarding the significant impairment with which her service-incurred condition continues to burden her. The Board wishes to clarify that it is subject to the same laws for service disability entitlements as those under which the Disability Evaluation System (DES) operates. The DES 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 (DVA), operating under a different set of laws (Title 38, United States Code). The Board evaluates DVA evidence proximal to separation in arriving at its recommendations, but its authority resides in evaluating the fairness of DES fitness decisions and rating determinations for disability at the time of separation. The Board further acknowledges the CI’s contention for ratings for other conditions documented at the time of separation, and notes that its recommendations in that regard must comply with the same governance. Painful Feet Condition. In May 2001, the CI developed gradual onset of bilateral foot pain without injury while at NTC training. She was maintained on temporary profiles and eventually referred to podiatry after X-rays and bone scans were negative. Podiatry diagnosed pes cavus, recommended custom orthotics and these did not give her significant relief. She was also evaluated by neurology that did not offer any further diagnoses. The permanent profile identified symptomatic pes cavus (very high arches) and documented the following limitations; all activities at own pace, distance and endurance, march up to 2 miles, lift up to 40 pounds, wear soft shoes with uniform, alternate Army Physical Fitness Testing as marked, pushups, sit- ups and bicycle. The commander’s statement documented the CI was working her MOS as a Motor Transport Operator, but in a limited capacity as a clerk in the operation section to accommodate her limitations, specifically the need to sit to relieve the pain and swelling in her feet. At the MEB exam, the CI reported very mild chronic pain in both feet at rest with a pronounced worsening of the pain after 10 to 15 minutes of standing. She was able to walk up to two miles despite this pain. She used over-the-counter arch supports in some of her civilian shoes. The MEB physical exam noted mild symptomatic pes cavus with tenderness to pressure over the first metatarsal heads bilaterally. Neurologic findings were negative. The podiatry consultant documented normal palpable pulses and the feet were painful. Range-of-motion (ROM) was full and complete, but elicited a positive facies dolorosa, (grimace due to pain). X-rays of the right and left foot and ankle revealed no evidence of fracture, dislocation, arthritic or inflammatory changes. The bone scan was normal. The examiner diagnosed metatarsalgia, with moderate symptoms with prolonged walking and standing, preventing the wearing of military footwear. At the VA Compensation and Pension (C&P) exam after separation, the CI reported after driving for a long time, running or standing her feet and hands would swell cramp and become numb and painful. Her primary problems were with her feet. She denied ever having an electromyogram and nerve conduction testing. She reported she was given insoles but they were not helpful and that she had to wear shoes that were one size too large. The C&P exam additionally demonstrated hip flexion, extension at the leg, dorsiflexion of the foot, wiggling and curling of the toes, eversion of the foot, and extension of the toes were all normal and 5 of 5 motor strength. She was able to tandem walk and stand on heels or toes. She complained of pain with gripping movements and with walking but was not currently symptomatic. The bilateral lower leg, ankle and foot exams were without edema with normal ankle ROM and without Deluca observations. The Board directs attention to its rating recommendation based on the above evidence. This rating includes consideration of functional loss lAW VASRD §4.10 (Functional impairment), §4.40 (Functional loss), §4.45 (DeLuca), and §4.59 (Painful motion). The PEB and VA chose different coding options for the condition which had some implications on the rating for the Board to consider. The PEB’s DA Form 199 reflected application of the USAPDA pain policy for rating and its 0% determination was inconsistent with §4.71a standards. The VA assigned a rating of 10% coded analogous to 5279 (metatarsalgia) with 5278 (pes cavus) for bilateral foot pain which fits the clinical pathology and is consistent with §4.71a standards. The Board considered the 5278 code (pes cavus) and agreed the evidence does not support the higher rating under this criterion. There is no evidence of documentation of incapacitating episodes or peripheral nerve impairment which would provide for additional or higher rating. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (Resolution of reasonable doubt), the Board recommends a disability rating of 10% for the painful feet condition. The action officer recommends analogous rating to 5278 with 5279, thus subsuming pes cavus and using 5279 as the primary code to capture the primary pain disability. Contended PEB Conditions. The contended conditions adjudicated as not unfitting by the PEB were mild carpal tunnel and idiopathic edema. The Board’s first charge with respect to these conditions is an assessment of the appropriateness of the PEB’s fitness adjudications. The Board’s threshold for countering fitness determinations is higher than the VASRD §4.3 (Resolution of reasonable doubt) standard used for its rating recommendations, but remains adherent to the DoDI 6040.44 “fair and equitable” standard. The Board notes the CI had a negative evaluation for idiopathic hand and feet swelling by primary care and specialty care evaluations. Extensive evaluation of laboratory data was also noncontributory towards specific or further diagnoses. With regards to the mild carpal tunnel, the MEB exam did note a decreased sensation in both hands in the distribution of the median nerve with a positive Phalen’s sign on the left (specific test for median nerve pathology), however there is no evidence of functional impairment. Idiopathic hand and feet swelling were implicated in the commander’s statement; however, none of these conditions were profiled; and, none were judged to fail retention standards. All were reviewed and considered by the Board. There was no indication from the record that either of these conditions significantly interfered with satisfactory duty performance. After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for any of the contended conditions and, therefore, no additional disability ratings can be recommended. 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. As discussed above, PEB reliance on the USAPDA pain policy for rating painful feet condition was operant in this case and the condition was adjudicated independently of that policy by the Board. In the matter of the painful feet condition, the Board unanimously recommends a disability rating of 10%, coded 5278-5279 IAW VASRD §4.71a. In the matter of the contended mild carpal tunnel and idiopathic edema conditions, the Board unanimously recommends no change from the PEB determinations as not unfitting. There were no other conditions within the Board’s scope of review for consideration. RECOMMENDATION: The Board recommends that the CI’s prior determination be modified as follows, effective as of the date of her prior medical separation: UNFITTING CONDITION VASRD CODE RATING Painful feet/metatarsalgia 5278-5279 10% RATING 10% The following documentary evidence was considered: Exhibit A. DD Form 294, dated 20120621, w/atchs Exhibit B. Service Treatment Record Exhibit C. Department of Veterans’ Affairs Treatment Record xxxxxxxxxxxxxxxxxxxxxxxx, DAF Acting Director Physical Disability Board of Review SFMR-RB MEMORANDUM FOR Commander, US Army Physical Disability Agency (TAPD-ZB / xxxxxxxxxx), 2900 Crystal Drive, Suite 300, Arlington, VA 22202-3557 SUBJECT: Department of Defense Physical Disability Board of Review Recommendation for xxxxxxxxxxxxxxxxxxxx, AR20130005077 (PD201200918) 1. 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 to modify the individual’s disability rating to 10% without recharacterization of the individual’s separation. This decision is final. 2. I direct that all the Department of the Army records of the individual concerned be corrected accordingly no later than 120 days from the date of this memorandum. 3. I request that a copy of the corrections and any related correspondence be provided to the individual concerned, counsel (if any), any Members of Congress who have shown interest, and to the Army Review Boards Agency with a copy of this memorandum without enclosures. BY ORDER OF THE SECRETARY OF THE ARMY: Encl xxxxxxxxxxxxxxxxxxxxxxx Deputy Assistant Secretary (Army Review Boards)