RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW NAME: XXXXXXXXXXXXXXXXX BRANCH OF SERVICE: ARMY CASE NUMBER: PD1201909 SEPARATION DATE: 20030510 BOARD DATE: 20130131 SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SGT/E-5 (91A20/Medical Repair Technician), medically separated for bilateral heel pain. He experienced an onset of bilateral heel pain in 1999 after participation in an airborne operation. His condition was diagnosed as a Haglund’s deformity and Achilles tendonitis. The symptoms failed to respond to conservative measures, and could not be adequately rehabilitated to meet the physical requirements of the CI’s 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 no other conditions for Physical Evaluation Board (PEB) adjudication. The PEB adjudicated bilateral heel pain, due to Haglund's deformity and Achilles tendonitis as unfitting, rated 0%, with cited application of the US Army Physical Disability Agency (USAPDA) pain policy. The CI made no appeals, and was medically separated. CI CONTENTION: “Under the review, I was classified as having a condition called bilateral Haglund Deformity. I believe that this condition occurred because of 5 years of training in a highly deployable airborne unit, the 82nd Airborne Division. I refused surgical treatment because I did not want to interfere with the natural attachment of the tendon to the bone. Until this day, I cannot run without inflaming the tendon, and I must wear heel pads to minimize rubbing when walking. Its a painful condition. ” 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 unfitting conditions will be reviewed in all cases. The bilateral heel pain, as requested for consideration, meets the criteria prescribed in DoDI 6040.44 for Board purview and is addressed below. 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 Army Board for Correction of Military Records. RATING COMPARISON: Service IPEB – Dated 20030317 VA - (5 Mos. Post-Separation) Condition Code Rating Condition Code Rating Exam Bilateral Heel Pain, Due to Haglund's Deformity and Achilles Tendonitis 5099-5003 0% Right Achilles Tendonitis with Haglund Deformity 5024 0% 20031021 Left Achilles Tendonitis with Haglund Deformity 5024 0% 20031021 No Additional MEB/PEB Entries Other x 5 20031021 Combined: 0% Combined: 40% VARD 20040214 (most proximate to Date of Separation) ANALYSIS SUMMARY: The Disability Evaluation System (DES) is responsible for maintaining a fit and vital fighting force. While the DES considers all of the member's medical conditions, compensation can only be offered for those medical conditions that cut short a member’s career, and then only to the degree of severity present at the time of final disposition. 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 nor for conditions determined to be service-connected by the Department of Veterans Affairs (DVA) but not determined to be unfitting by the PEB. However, the DVA, operating under a different set of laws (Title 38, United States Code), is empowered to compensate all service-connected conditions and to periodically re-evaluate said conditions for the purpose of adjusting the Veteran’s disability rating should the degree of impairment vary over time. The Board’s role is confined to the review of medical records and all evidence at hand to assess the fairness of PEB rating determinations, compared to VASRD standards, based on severity at the time of separation. Bilateral Heel Pain. The CI developed pain in the left heel in 1999. The diagnosis of Haglund’s deformity was made 21 March 2000. In October 2001, the CI first noted additional pain in the right heel. X-rays obtained 7 February 2002 confirmed calcifications at the insertion of both Achilles tendons confirming the diagnosis of Haglund’s deformity. On examination on 22 August 2002 a small deformity only of the left heel was noted. In October 2002, 7 months before separation, the CI successfully completed a standard PT test. On 30 October 2002 the CI noted pain in both heels, with the left worse than the right. At a clinic visit on 1 November 2002, the CI had pain in only the left heel. At the MEB/narrative summary (NARSUM) exam performed 8 January 2003, 4 months before separation, the CI reported bilateral heel pain described as occasional and moderate. On physical examination, small, tender masses were present at the Achilles tendon attachments to the heels bilaterally with left larger than the right. At the VA Compensation and Pension (C&P) exam 21 November 2003, 5 months after separation, the CI reported pain at the base of both heels. He noted no restrictions in any activity from the conditions; no requirement for pain medication or care by a podiatrist and no use of orthotics, or assists in ambulation. He reported running a mile and half every day and being able to bench press 300 pounds. On physical examination, tenderness was noted at the base of each Achilles tendon without shift in weight bearing line, callous formation or pronation deformity. Range-of-motion (ROM) of the ankles was normal without instability or incoordination. The Board directs attention to its rating recommendation based on the above evidence. The PEB combined both heel conditions and rated as a single unfitting condition, 0%, code 5009- 5003, using the Army Pain policy. Not uncommonly this approach by the PEB reflected its judgment that the constellation of conditions was unfitting, and there was no need for separate fitness adjudications or implied adjudication that each condition was separately unfitting. The VA rated the ankle conditions each separately at 0% coded 5024, tenosynovitis, citing normal ankle ROM. The Board considered unbundling the PEB adjudication for individual ratings. The Board, in this circumstance, maintains the prerogative of separate fitness recommendations, with the caveat that its recommendations may not produce a lower combined rating than that of the PEB. The Board first addressed the fitness of each individual heel condition. The Board opined that both heel conditions were symptomatic and prevented the CI from performing the duties of his MOS as documented in the profiles, commander’s statement, and NARSUM. The Board then considered the appropriate rating for the individual right and left heel conditions. The Board agreed that neither heel condition was compensable under code 5024 based ROM. The Board noted that both heel conditions were mildly tender on examination throughout the record with left greater than right. The Board considered rating under §4.59 (painful motion) but opined that the absence of impact on functional activity, activities of daily living and exercise documented in the record did not rise to the 10% disability level for either heel condition. The Board concluded that the record in evidence supported a 0% rating for each heel. The Board further agreed that the minor deformities of the heel bones (Haglund’s deformity) were related to the tendinitis of the Achilles tendon at the site of attachment, and were an integral part of the heel condition, not subject to additional rating IAW VASRD §4.14 (avoidance of pyramiding). The Board was unable to find a pathway to any higher rating under any other applicable VASRD coding. 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 adjudication for the bilateral heel pain condition as any change in coding, or individual rating after unbundling, provided no benefit to the CI. 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 bilateral heel pain condition was operant in this case and the condition was adjudicated independently of that policy by the Board. In the matter of the bilateral heel pain 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 Bilateral Heel Pain Due to Achilles Tendonitis with Haglund’s Deformity 5099-5003 0% COMBINED (w/ BLF) 0% The following documentary evidence was considered: Exhibit A. DD Form 294, dated 20121107, w/atchs Exhibit B. Service Treatment Record Exhibit C. Department of Veterans’ Affairs Treatment Record xxxxxxxxxxxxxxxxxxxxxx, 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 xxxxxxxxxxxxxxxxxxxxxxxxxx, AR20130007496 (PD201201909) 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)