RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW NAME: XXXXXXXXXXXXXXXX BRANCH OF SERVICE: ARMY CASE NUMBER: PD1201224 SEPARATION DATE: 20020829 BOARD DATE: 20130306 SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty PV2/E-2 (68S10/Preventive Medicine Specialist), medically separated for pain left foot with stress fractures of the second and third metatarsals and stress reaction of the left foot. The CI had a history of chronic left foot and ankle pain since early advanced infantry training (AIT). He denied a history of injury. The CI 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 L3 profile and referred for a Medical Evaluation Board (MEB). The MEB forwarded stress fracture of the third metartarsal, possibly the second metatarsal and stress reactions to left foot per bone scan conditions, identified in the rating chart below, as being medically unacceptable. The Physical Evaluation Board (PEB) adjudicated pain left foot with stress fractures of the second and third metatarsals and stress reaction left foot condition as unfitting rated 10%, with likely application of the Veterans Affairs Schedule for Rating Disabilities (VASRD). The PEB combined the two MEB conditions into one unfitting condition. The CI made no appeals and was medically separated with a 10% disability rating. CI CONTENTION: “Stress Fractures on Foot due to boots being to small & lose of hearing.” sic 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. Ratings for unfitting conditions will be reviewed in all cases. The rated, unfitting condition (pain left foot with stress fractures of the second and third metatarsals and stress reaction left foot) as requested for consideration meet the criteria prescribed in DoDI 6040.44 for Board purview. The other requested condition (loss of hearing) 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 respective Board for Correction of Military Records. The Board acknowledges the CI’s information regarding the significant impairment with which his service-connected condition continues to burden him; but, must emphasize that the Disability Evaluation System (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 Veteran Affairs, operating under a different set of laws. Post-separation evidence is probative to the Board’s recommendations only to the extent that it reasonably reflects the disability at the time of separation. RATING COMPARISON: Service IPEB – Dated 20020725 VA - (~1 Mo. Post-Separation) 20020830 Condition Code Rating Condition Code Rating Exam Pain L Foot w/ Stress 5279 10% S/P L Third Metatarsal Fx… 5279 10%* 20030521 No Additional MEB/PEB Entries NSC x 5 20030521 Combined: 10% Combined: 10% VARD 20030712 (most proximate to Date of Separation) * Rating increased to 20% from 20020830 and VASRD Code changed to 5284. Overall combined rating was 30% when VA added Tinnitus at 10% from 20020830. No Second foot C&P exam in CPF. ANALYSIS SUMMARY: Pain Left Foot with Stress Fractures of the Second and Third Metatarsals and Stress Reaction Left Foot. The CI presented for left foot and ankle pain in early AIT without specific injury. X- rays were negative and he was treated conservatively without resolution of his pain. A bone scan revealed stress reactions throughout the left foot and a healing stress fracture of the third metatarsal which was consistent with a recent X-ray. He was issued a L3 profile and referred to MEB. At the MEB examination 2 months prior to separation, the CI reported a 7 month history of pain and that he could not bear his full weight. He was using a brace at the examination. The narrative summary (NARSUM) was dictated 3 days later by an orthopedic surgeon. The CI reported that his pain prevented him from meeting the requirements of his MOS and noted that the CI requested separation. It was noted that he had healing stress fractures of the third and possible second metatarsal bones, but was without tenderness over the bones and had no soft tissue changes. At the VA Compensation and Pension (C&P) exam performed 9 months after separation, the CI reported continued pain of the left foot relieved with non-weight bearing. He used no assistive devices and took Ibuprofen for pain. He was working at a local store stocking shelves. On examination, his gait was mildly antalgic. No signs of muscle wasting were present. The foot was mildly tender over the second and third metatarsals. No swelling was present. He wore new shoes, so an assessment for abnormal wear was not possible. X- rays of the left foot and ankle were done, but the results not annotated. He was diagnosed as status post (s/p) left third metatarsal fracture with persistent metatarsalgia (pain). The Board directs attention to its rating recommendation based on the above evidence. The VA and PEB both rated the left foot condition at 10% and coded it 5279, metatarsalgia. The Board noted that, as documented on the 21 November 2006 VA Rating Decision (VARD), the VA subsequently changed the coding to 5284, other foot injuries, and increased the rating to 20% retroactive to separation. However, neither the C&P nor the VARD specific to this increase were in the records available for review. The PEB combined the two MEB diagnoses into one unfitting condition. The primary symptom was pain with weight bearing. The Board determined that the two conditions could not be severed for rating purposes without violation VASRD §4.14, (Avoidance of pyramiding). The Board noted that the CI was employed stocking shelves after separation and that the stress fracture had healed the expected clinical course. The metatarsals were non-tender at the MEB examination and minimally so at the C&P almost a year later. No muscle loss was present and no assistive devices in use. The Board determined that the examinations proximate to separation do not support a moderately severe disability to justify a 20% rating under the code 5284 and that no other code provided a route to a higher rating adjudicated by the PEB and VA at the time of separation. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (Resolution of reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the left foot condition. 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 pain in the left foot condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication. 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 Pain Left Foot with Stress Fractures of the Second and Third Metatarsals and Stress Reaction Left Foot 5279 10% COMBINED 10% The following documentary evidence was considered: Exhibit A. DD Form 294, dated 20120614, w/atchs Exhibit B. Service Treatment Record Exhibit C. Department of Veterans’ Affairs Treatment Record xxxxxxxxxxxxxxxxxxxxxxxxxx, DAF Acting Director Physical Disability Board of Review SFMR-RB MEMORANDUM FOR Commander, US Army Physical Disability Agency (TAPD-ZB / xxxxxxxxxxxx), 2900 Crystal Drive, Suite 300, Arlington, VA 22202-3557 SUBJECT: Department of Defense Physical Disability Board of Review Recommendation for xxxxxxxxxxxxxxxxxxxxxxxx, AR20130008714 (PD201201224) 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 xxxxxxxxxxxxxxxxxxxxxx Deputy Assistant Secretary (Army Review Boards)