RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-00074
BRANCH OF SERVICE:  Army	BOARD DATE:  20150320
SEPARATION DATE:  20070917

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (Multi-Channel Transmission Systems Operator-Maintainer) medically separated for pain in his feet.  This condition could not be adequately rehabilitated to meet the requirements of his Military Occupational Specialty (he was able to participate in alternate fitness testing), so he was issued a permanent L3 profile and referred to a Medical Evaluation Board (MEB).  The “congenital pes planus” (flat feet) and “metatarsalgia” (pain in the ball of the foot) were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501, along with “Gastroesophageal reflux disease” (GERD; this last condition was listed as medically acceptable).  The Informal PEB adjudicated “metatarsalgia, bilateral…” as unfitting, rated 10%, with likely application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The remaining condition (GERD) was determined to be not unfitting.  The CI made no appeals and was medically separated.

CI CONTENTION:  “After separation, I had to have surgery to remove nerves from the left foot.  Also had multiple visits resulting in steroid multiple injections.  Still have pain in both feet.  Have lost partial feeling in the left foot where neuromas were removed.  I received a service connection for GERD but was awarded 0%, I would like that re-evaluated.  Take a pill for it twice a day but still struggle with it.  Thank you for re-evaluating GERD, Pes Planovalgus, and bilateral metatarsalgia.  Thanks.”

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 when specifically requested by the CI, those conditions identified by the PEB, but determined to be not unfitting.  Any conditions outside the Board’s defined scope of review and any contention not requested in this application may remain eligible for future consideration by the Board for Correction of Military/Naval Records.  Furthermore, the Board’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The Board’s assessment of the PEB rating determinations is confined to review of medical records and all available evidence for application of the VASRD standards to the unfitting medical condition at the time of separation.  The Board has neither the role nor the authority to compensate for post-separation progression or complications of service-connected conditions.  That role and authority is granted by Congress to the Department of Veterans Affairs, operating under a different set of laws.  The Board gives consideration to VA evidence, particularly within 12 months of separation, but only to the extent that it reasonably reflects the severity of the disability at the time of separation.

RATING COMPARISON:

IPEB – Dated 20070807 | VA* - (~3 Mos. Post-Separation)
Condition | Code | Rating | Condition | Code | Rating | Exam
Metatarsalgia, Bilateral… | 5279 | 10% | Bilateral Metatarsalgia… | 5276-5279 | 10% | 20071212
GERD | Not Unfitting | Esophageal Reflux | 7399-7346 | 0% |
Other x0 | Other x6
RATING:  10% | RATING:  10%
*Derived from VA Rating Decision (VARD) dated 20080107 (most proximate to date of separation [DOS])

ANALYSIS SUMMARY:

Bilateral Metatarsalgia.  The evidence supports that the CI had “mild asymptomatic pes planus” documented on his entrance physical examination dated October 2003.  He had no foot complaints until January 2006 when initially his left foot then the right began hurting him.  There was no acute injury noted, however, he had increased his running and bought new running shoes around that time and his left foot was more symptomatic than the right.  He was evaluated by primary care and podiatry with plain film X-rays and magnetic resonance imaging (MRI) studies, both were essentially normal.  He was given custom shoe inserts, activity restriction, and eventually had his left foot immobilized for 12 weeks without resolution of his foot pain.  In June 2006 he had a repeat plain film X-ray that revealed “Mild flattening of the feet with small heel spurs.”  Also in June 2006, he was deployed to Kuwait but returned state-side due to bilateral foot pain prior to completing that deployment.  During that deployment he was evaluated by orthopedics and podiatry with another essentially normal MRI of the left foot and treated with extensive physical therapy.  When his foot pain continued he was entered into the Disability Evaluation System.  The narrative summary prepared 2 months prior to separation noted because he was unable to return to full duty in the combat theater, he was evacuated to the regional medical center where he received steroid injections.  On return to Kuwait, an orthopedic evaluation documented that he was unable to return to full duty because of the metatarsalgia from the bilateral pes planus.  Physical exam revealed a normal gait; however, a limp appeared with jogging as the CI tended to minimize the weight on his left foot.  The left arch was flat, left greater than right, and with marked increased pronation.  There was tenderness to palpation (TTP) of the lateral left foot without swelling.  Both ankles had full range-of-motion (ROM) and there was no painful motion noted.  A bone scan in November 2006 revealed diffuse uptake within the ankles, mid feet, hind-feet, and posterolateral ankle consistent with moderate stress-related changes.  At the VA Compensation and Pension exam performed 3 months after separation, the CI reported constant 6/10 burning, aching, sharp pain on the bottom of his feet for 2 years.  The pain increased with activity, relieve by rest and “At rest he has no pain, weakness, swelling and fatigue.”  He used Motrin with poor response.  The physical exam revealed no signs of abnormal weight bearing on the feet.  Bilateral ankle ROM was normal without any Deluca criteria.  Both feet were tender to palpation; however, there was no painful motion of either foot.  There was pes planus present but no abnormal Achilles tendon alignment and no marked pronation of either foot.  The C&P examiner also included, “He does not have any limitation with standing and walking. He does not require any type of support with his shoes.”

The Board directed attention to its rating recommendation based on the above evidence.  The PEB applied VASRD code 5279 (anterior metatarsalgia) and rated it 10%, the only rating available for that code.  The VA applied the combination code 5276 (acquired flat foot) with 5279 and also rated it 10% citing criteria from both codes.  All evidence supports that the CI had pain on the bottom of both feet that was due to pes planus and metatarsalgia.  Both conditions are represented in the VASRD, and both have unilateral or bilateral ratings available.  Along with code 5279, the “moderate” rating under code 5276 has only one rating, 10% for either unilateral or bilateral acquired flatfoot.  The Board reviewed the record for evidence that would support a recommendation for the next higher “severe,” (20% for unilateral or 30% for bilateral) rating under 5276.  The criteria for the severe rating are, “objective evidence of marked deformity (pronation, abduction, etc.), pain on manipulation and use accentuated, indication of swelling on use, and characteristic callosities.”  No exam or service treatment record entry documented characteristic callosities, marked deformity or any swelling on use within a year of separation.  There was some tenderness to palpation of the feet but no painful motion.  Board members agree that the evidence present for review does not support a recommendation of the “severe” rating for the CI’s bilateral foot condition.  Additionally, the Board noted that there is no path to a higher rating as the VASRD specifies bilateral ratings for the conditions responsible for the CI’s impairment.  Considering the totality of the evidence and mindful of VASRD §4.3 (reasonable doubt), members agreed that the disability rating of 10% for the bilateral metatarsalgia condition was appropriately recommended in this case.

Contended Gastroesophageal Reflux Disease Condition.  The Board’s main charge is to assess the fairness of the PEB’s determination that the GERD was not unfitting.  The Board’s threshold for countering fitness determinations requires a preponderance of evidence, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.  The GERD condition was not profiled or implicated in the commander’s statement as causing duty limitation, and was not judged to fail retention standards.  All entries were reviewed and considered by the Board.  There was no performance based evidence from the record that this condition 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 the contended GERD condition and so no additional disability rating is 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.  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 metatarsalgia condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended GERD condition, the Board unanimously recommends no change from the PEB determination as not unfitting.  There were no other conditions within the Board’s scope of review for consideration.

RECOMMENDATION:  The Board, therefore, recommends that there be no re-characterization of the CI’s disability and separation determination.

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20131226, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

XXXXXXXXXXXXXXX 
President 
DoD 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 XXXXXXXXXXXXXXXXXXXX, AR20150012767 (PD201400074)

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			XXXXXXXXXXXXXXXXXXXX
				Deputy Assistant Secretary of the Army
				     (Review Boards)
						         
CF: 
(  ) DoD PDBR
(  ) DVA

PD-2014-00074