RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXX	CASE:  PD-2013-01412
BRANCH OF SERVICE:  Army	BOARD DATE:  20141030
SEPARATION DATE:  20041101

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty PFC/E-3 (88M/Truck Driver) medically separated for a right foot condition.  The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty or satisfy physical fitness standards.  He was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  The right foot condition, characterized as “chronic right midfoot pain (Lisfranc joint) secondary to mal-alignment and degenerative arthritis,” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other conditions were submitted by the MEB.  The Informal PEB adjudicated “right foot pain post fractures of the III and IV metatarsals that required open reduction and internal fixation (ORIF),” as unfitting, rated 0%, with likely application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The CI made no appeals and was medically separated.

CI CONTENTION:  “My commanders made me perform physical fitness while wearing hard and soft cast on my right foot making injury worse.  I’m still to this day in constant pain and nothing”….pg 2 missing of application

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 rating for the unfitting right foot condition is addressed below; no additional conditions are within the DoDI 6040.44 defined purview of the Board.  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 Board for Correction of Military Records.

RATING COMPARISON:

Service IPEB – Dated 20040815	VA – (1Mos. Pre-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Foot Pain	5003	0%	Residuals, ORIF Lisfranc
Joint Right Foot	5283	30%	20041014	
Other x 0% (Not in Scope)	Other x 1	
Combined:  0%	Combined:  40%	
Derived from VA Rating Decision (VARD) dated 20041213 (most proximate to date of separation [DOS]).

ANALYSIS SUMMARY:

Right Foot Condition.  Treatment records show the CI initially injured his right foot (fracture and dislocation of the tarsal-metatarsal [Lisfranc] joint) on 27 April 2003 while descending concrete steps.  X-ray completed on 29 April 2003 by orthopedic surgery showed minimally displaced third and fourth metatarsal (midfoot bone) neck fractures.  Second X-ray completed on 20 November 2003 showed dorsal displacement of the first and lateral displacement of the second metatarsals.  The CI failed conservative therapy (immobilization, temporary profile, anti-inflammatory medications, arch supports) and elected to have surgery.  On 7 January 2004, podiatry performed ORIF with good alignment using two surgical wires.  On 24 February 2004 podiatry removed the cast and wires.  The post-operative weight bearing X-ray was essentially unchanged from the 20 November 2003 X-ray.  It showed widening between the bases of the first and second metatarsals and a mild offset of the second metatarsal.  At the 22 March 2004 podiatry encounter, the CI complained that pain had not improved much following surgery.  X-ray completed the same day showed return of the preoperative diastasis (abnormal dislocation or separation) about the Lisfranc joint, with lateral subluxation (incomplete or partial dislocation) of the second metatarsal base.  The podiatrist noted no significant relief from the attempted surgical realignment and did not recommend surgical fusion of the Lisfranc joint.

The 26 April 2004 MEB narrative summary, (6 months prior to separation) by podiatry reported that conservative treatment was unsuccessful and surgical realignment failed over the long term.  The CI complained of intermittent sharp and dull pain with ambulation.  Pain was exacerbated by activity, prolonged standing and load bearing.  It was relieved by staying off his feet and wearing soft shoes.  The CI indicated that his pain had worsened since his initial injury, but was not taking pain medications.  The physical exam was within normal limits with the exception of the right foot.  With weight bearing, there was slight depression of the right medial longitudinal arch compared to the left.  Rising on his toes and squatting caused pain about the Lisfranc joint.  There was mild midfoot edema and tenderness at the Lisfranc joint.  Stress abduction caused Lisfranc joint pain with no dislocation seen on fluoroscopy (real-time X-ray video images).  Stress dorsiflexion caused a palpable click at the Lisfranc joint with no instability visualized on fluoroscopy.  The podiatrist noted that the 22 March 2004 X-ray showed diastasis at the Lisfranc joint with the second metatarsal displaced laterally.  Healed fractures and early degenerative arthritis was seen in multiple joints consistent with his past injury.  The diagnosis listed chronic right Lisfranc joint pain secondary to malalignment and degenerative arthritis.  The podiatrist opined that the CI’s condition would progressively worsen due to instability and degenerative arthritis.  He recommended delaying surgical fusion of the affected joints.  The 14 October 2004 (2 weeks prior to separation) VA Compensation and Pension (C&P) exam recorded the previously established clinical and surgical course.  The CI complained of right midfoot tenderness with standing (more than 10 minutes) and walking (more than 30 paces).  He could not do high impact activities such as running, jumping or marching.  Physical exam documented a normal gait and normal station without the use of aids for ambulation.  The right foot exam showed well-healed surgical scars, no bony abnormality and a 5-degree internal rotation.  The medial Lisfranc joint was tender to palpation.  The examiner opined the condition caused a major amount of physical impairment because of the pain.

The Board directs its attention to its rating recommendation based on the above evidence.  The PEB rated the right foot condition 0% and used VASRD code 5003 (degenerative arthritis) citing pain and arthritis in several minor joints.  The VA rated it 30% and used code 5283 (tarsal, or metatarsal bones, malunion of or nonunion of; severe) citing pain, misalignment of the Lisfranc joint and degenerative arthritis.  The post-operative X-rays showed healed metatarsal fractures and mild lateral displacement of the second metatarsal.  The proximate histories (MEB and C&P) documented intermittent midfoot pain, exacerbated by prolonged standing, activity and weight bearing.  The CI was not taking medications for pain.  The MEB documented a normal physical exam with the exception of the right foot slight arch depression and mild edema.  There was Lisfranc joint tenderness, pain with motion, pain with stress and a palpable click with stress.  The examiner opined that the condition impacted the CI’s ability to perform military duties.  The C&P exam documented a normal station, normal gait without aids for ambulation and absent limp.  The right foot exam showed well-healed surgical scars, no bony abnormality, 5 degrees of foot rotation and Lisfranc joint tenderness.  The examiner opined that the condition caused the CI major physical impairment because of the pain.  The VASRD code used by the VA rates based on impairment as moderate (10%), moderately severe (20%) and severe (30%).  Actual loss of use of the foot is rated 40%.  Board members discussed whether the limitations and exam findings described more nearly approximated moderate, moderately severe, or severe impairment.  Members concluded the normal gait on the C&P exam favored the moderate or moderately severe impairment.  Members noted the VA rating for severe (30%) impairment but agreed the condition more nearly approached moderately severe impairment based upon subjective complaints and objective exam and imaging findings.  The Board also considered VASRD code 5276 for acquired flatfoot.  The CI’s symptoms were improved, but not relieved, with orthotics consistent with moderate (10%, unilateral or bilateral) impairment under this code.  All members agreed the condition did not exceed the moderate level as the 20% rating would require severe unilateral disability, evidence of marked deformity, accentuated pain on manipulation and use, swelling on use, or characteristic callosities.  The Board also considered whether a higher rating was supported under VASRD codes 5284, 5310, 5311 and 5312.  No benefit resulted under these codes as the impairment associated with the condition was not severe.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 20% for the right foot condition (5283).

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 right foot condition, the Board unanimously recommends a disability rating of 20%, coded 5283 IAW VASRD §4.71a.  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 his prior medical separation:

UNFITTING CONDITION	VASRD CODE	RATING	
Right Foot Pain	5283	20%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20130916, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

				

XXXXXXXXXXXXXXX
President
Physical Disability Board of Review

SAMR-RB			

MEMORANDUM FOR Commander, US Army Physical Disability Agency 
(AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation 
for XXXXXXXXXXXXXXX, AR20150004183 (PD201301412)

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 20% 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						     XXXXXXXXXXXXXXX
						     Deputy Assistant Secretary of the Army
						         (Review Boards)

CF: 
(  ) DoD PDBR
(  ) DVA