RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-01004
BRANCH OF SERVICE:  Army	BOARD DATE:  20150629
Separation Date:  20081026

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (Automated Logistics Specialist) medically separated for bilateral pes planus.  The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty but the CI was authorized to perform an alternate physical fitness test per PROFILE.  He was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  The “bilateral pes planus deformity” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also identified and forwarded one other condition (“right lateral leg soft tissue mass”) for PEB adjudication.  No other condition was submitted by the MEB.  The Informal PEB adjudicated “moderate bilateral pes planus deformity” as unfitting, rated 10% with likely application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The remaining condition was determined to be not unfitting.  The CI made no appeals and was medically separated.

CI CONTENTION:  “My disability keeps me from standing on my feet for long periods of time.  I am currently receiving Social Security Disability because of this.  I am having a hard time making ends meet.  A higher disability rating would help me make ends meet.  Because of this injury I am unable to seek a career in law enforcement which is what I got my college education in.  I was granted disability compensation for intermittent claudication.”  [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 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 20080722 | VA* - (~1 Mos. Post-Separation)
Condition | Code | Rating | Condition | Code | Rating | Exam
Moderate Bilateral Pes Planus Deformity | 5276 | 10% | Bilateral Pes Planus | 5276 | NSC** | 20080903
Right Lateral Leg Soft Tissue Mass | Not Unfitting | Right Calf Intermittent Claudication | 7199-7120 | 10% | 20080903
Other x 0 (Not In Scope) | Other x 1
RATING:  10% | RATING:  10%
*Derived from VA Rating Decision (VARD) dated 20100210 (most proximate to date of separation [DOS]) **The VA awarded unemployability to the CI based on this disability.

ANALYSIS SUMMARY:  IAW DoDI 6040.44, the Board’s authority is limited to making recommendations on correcting disability determinations.  The Board’s role is thus confined to the review of medical records and all evidence at hand to assess the fairness of PEB rating determinations, compared to VASRD, based on ratable severity at the time of separation.

Moderate Bilateral Pes Planus Deformity Condition.  The CI developed bilateral pain in his arches with marching and running in February 2008.  The podiatrist in 2007 and 2008 documented clinical evidence of pes planus (decreased medial longitudinal arch bilaterally).  Weight bearing X-rays performed in 2007 and 2008 were normal.  Custom orthotics did not relieve his bilateral foot pain.  The CI was given a permanent L3 profile for flat foot with additional code C restrictions noted on the profile.  The CI was able to perform the alternate aerobic event for fitness testing.  The MEB podiatry narrative summary examination approximately 6 months prior to separation documented that the CI had daily, sharp, sore pain in the plantar aspects (bottom surface) of both feet which was limited to the arches just prior to the balls of his feet.  There were physical examination findings of normal medial longitudinal arches when non-weight bearing, but on weight bearing there was significant (severe) decrease of the arches and abnormal heel tilt relative to the leg; right greater than left.  The examiner opined that the physical findings were “consistent with more than a moderate deformity.”  The examiner noted that the radiologist described the February 2008 X-rays indicative of moderate bilateral pes planus deformity; however the examiner opined that the clinical and functional findings demonstrated that the pes planus caused a severe impact on the CI’s duty performance with a poor prognosis.  The MEB podiatry addendum 3 months prior to separation documented that the CI reported pain in both feet within 10 minutes of wearing any foot wear including military boots.  He had constant soreness rated at 4/10 and within 15 to 30 minutes of activity the pain increased to 10/10.  There were physical examination findings of pes planus with significant inward movement of the foot (pronation), small amount of callus (normal pattern) on the plantar surface of the distal great toes, and tenderness of the plantar surface (over the arch from the metatarsal heads to the anterior calcaneus, and laterally in the mid foot and mid portion of the anterior calcaneus) bilaterally.  The examiner diagnosed clinically severe bilateral pes planus unresponsive to treatment.  The VA Compensation and Pension (C&P) a month prior to separation documented that the CI had bilateral sharp, throbbing pain in the heel and arch with occasional pins and needle sensation in the arch.  He had daily flares of moderate pain with walking, playing sports which was relieved with rest and medication.  He reported pain, fatigability, and callouses.  There were physical examination findings of flat feet, no abnormal skin findings, and a normal gait.  The right foot examination demonstrated tenderness of the plantar surface at the distal arch and mild pronation.  The left foot examination demonstrated moderate pronation, tenderness of the plantar surface of the lateral arch, and weight bearing over or medial to the great toe (abnormal weight bearing).

The Board directed attention to its rating recommendation based on the above evidence.  The PEB coded the moderate bilateral Pes Planus deformity condition 5276 (Pes Planus) and rated at 10%.  The VARD on 10 February 2010 documented that “a decision on entitlement to compensation for Pes Planus is deferred.”  A VARD dated 8 March 2010 documented that based on a VA medical expert review that concluded that the pes planus had not been aggravated beyond normal progression by the military service.  VA was did not grant service-connection for the bilateral pes planus condition for VA compensation, but did service-connect the condition for vocational rehabilitation purposes.  The Board considered whether the evidence supported a higher than 10% rating.  The Board noted that the MEB examination 6 months prior to separation described the pes planus condition as severe; however the MEB addendum and VA examinations were most proximate to separation and assigned higher probative value.  The Board considered the clinical descriptors used to quantify the severity of pronation [significant (MEB), mild left (VA) and moderate right (VA)] in conjunction with radiograph evidence of moderate deformity.  Board members agreed that the evidence did not rise to the level of severe for a 30% rating.  The Board determined that the evidence of pain on manipulation and with use and left foot weight bearing line over or medial to the great toe most closely approximated moderate pes planus for a 10% rating.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% for the bilateral pes planus condition.

Contended PEB Conditions.  The contended condition adjudicated as not unfitting by the PEB was right lateral leg soft tissue mass.  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 (reasonable doubt) standard used for its rating recommendations, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.  There was evidence in the service treatment record that the CI had pain in his right leg with activity and was diagnosed with a varicose vein in the right shin.  A note from the medical examiner noted that the “issue is ongoing and inadequately treated over the past year as the Soldier has both claudication due to varicose vein” and pes planus.  He further opined that from the history symptoms did not match the current profile.  The CI had several temporary profiles for intermittent claudication - the last being on 5 February 2008 which indicated leg pain from a combination of varicose veins and flat feet although he was not given a permanent profile for this condition.  The soft tissue mass condition was not mentioned in the commander’s statement; and, nor was this condition judged to fail retention standards.  A MEB addendum approximately 3 months prior to separation documented that the CI had been evaluated by two vascular surgeons who both reported no arterial insufficiency; however one opined that this was a varicose vein and the other opined that it was a fascial hernia.  The CI reported that when he ran the mass would enlarge and was painful.  The examiner noted that the CI reported that an ultrasound done was “normal.”  There were physical exam findings of a visible 2cm mass in the right lateral leg at about mid shin level slightly tender without discoloration and no pulse palpable within it.  The examiner opined that this soft tissue mass was most likely a fascial hernia, although a small lipoma could not be ruled out.  The examiner further opined that it was unlikely to be a varicosity.  The VA C&P examiner documented that the CI had intermittent claudication with prolonged walking at a fast pace and relieved with stopping the activity and massage.  There were physical exam findings of a decreased tibial pulse, and a right lower extremity abnormality.  This condition was reviewed by the action officer and considered by the Board.  The CI had several temporary profiles for intermittent claudication from the varicose vein in the right lower extremity.  The Board agreed that the CI had a varicosity which caused pain in the right lower extremity with activity such as running.  They further agreed the preponderance of evidence demonstrated that the intermittent claudication pain was relieved with rest and massage.  There was disagreement between two vascular surgeons as one diagnosed a fascial hernia and the other diagnosed a varicosity.  There was evidence proximate to separation that the CI suffered from intermittent claudication due to the soft tissue mass when he performed any activity.  The CI was unable to march or run which significantly interfered with satisfactory duty performance.  The Board considered the rating criteria for 7120 (Varicose veins of) and determined that it rose above the 0% rating for asymptomatic palpable or visible varicose veins.  Board members agreed that the condition most closely approximated the 10% rating criteria of intermittent edema of extremity or aching and fatigue in leg after prolonged standing or walking, with symptoms relieved by elevation of extremity or compression hosiery.

After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was sufficient evidence  to recommend the Intermittent Claudication  condition be added as an additional unfitting condition and recommends a 10% rating coded 7120 IAW §4. 104.

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 pes planus condition, the Board unanimously recommends no change to the PEB adjudication.  In the matter of the contended Intermittent claudication condition, the Board by a majority vote agrees that it was unfitting; and recommends a disability rating of 10%, coded 7120 IAW VASRD §4.104.  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
Bilateral Pes Planus | 5276 | 10%
Intermittent Claudication | 7120 | 10%
COMBINED (w/ BLF) | 20%

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140218, 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, AR20150015754 (PD201401004)

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						     XXXXXXXXXXXXXXXXXXXX
						     Deputy Assistant Secretary of the Army
						         (Review Boards)

CF: 
(  ) DoD PDBR
(  ) DVA