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AF | PDBR | CY2012 | PD2012 01495
Original file (PD2012 01495.rtf) Auto-classification: Denied
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:    CASE: PD1201495
BRANCH OF SERVICE: ARMY  BOARD DATE: 20130410
SEPARATION DATE: 20030219


 SUMMARY OF CASE : Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SPC/E-4 (98G10/Voice Intercept) medically separated for a bilateral foot condition. She developed right foot pain in Basic Training, progressing to bilateral pain as her service progressed. Her diagnoses are as elaborated in her condition nomenclature below; and, she did not respond satisfactorily to orthotics and other podiatric interventions. She consequently could not meet the physical requirements of her Military Occupational Specialty (MOS) or satisfy physical fitness standards. She was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB). The condition(s), characterized as “chronic bilateral foot pain with hallux valgus, bunions, history of metatarsal stress fractures, and pes planus”, forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. The MEB also identified and forwarded five other conditions (as identified in the rating chart below) for PEB adjudication. The Informal PEB (IPEB) adjudicated the MEB submission as a single unfitting bilateral condition, rated 0%, with likely application of AR 635-40 (B.24 f.). The CI appealed to a Formal PEB (FPEB), which did not substantially alter the outcome, and was medically separated with a 0% disability rating.


CI CONTENTION: “VA gave 100% rating for PTSD [post-traumatic stress disorder] as well as ratings for both feet that rendered unfit that require ongoing extremities manipulation and taping with special foot ware. Other consideration, also Prevent return to civilian work of professional ski instructor. Male- last enlisted Army issue boot on female (i.e. 1 of 5 normal, healthy female foot shape types) bound the fore foot, and with excessive loose heel motion forced against incompatible curve/semi-curve permanently broke down foot mechanics. Left foot condition and right foot condition, each, rated by VA.”


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 foot condition(s) is addressed below. The posttraumatic stress disorder (PTSD) condition referenced in the application was not identified by the PEB, and thus is not within the DoDI 6040.44 defined purview of the Board. That, and any other conditions or contention not requested in this application, remain eligible for future consideration by the Board for Correction of Military Records.


 RATING COMPARISON :

Service FPEB – Dated 20021031
 VA - (~1 Mo. Pre-Separation)
Condition
 Code Rating Condition Code Rating Exam
Bilateral Foot Pain ... 5099 5022 0% Left Metatarsalgia ... 5299-5284 10% 20030318
Right Metatarsalgia ... 5299-5284 10% 20030318
Bilateral Carpal Tunnel Syndrome (CTS) Not Unfitting Right CTS 8515 30% 20030318
Left CTS 8515 20% 20030318
Depressive Disorder, NOS Not Unfitting Depressive Disorder... with Irlen's Syndrome 9399-9434 0% 20030318
Irlen Syndrome Not Unfitting
Mild Depression Not Unfitting
ADHD Not Compensable/? Administratively Unfitting No VA Entry
No Additional MEB/PEB Entries
 Other X 5 / Not Service Connected x 12 20030318
Combined: 0%
 Combined: 70%
Deriv ed from VA R ating Decision(VARD) dated 20030626 (most proximate to the date of separation)


ANALYSIS SUMMARY: The Board also acknowledges the CI's contention suggesting that ratings should have been conferred for conditions not diagnosed while in the service (but later determined to be service-connected by the VA). The Board wishes to clarify that it is subject to the same laws for service disability entitlements as those under which the Disability Evaluation System (DES) operates. 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. However, the Department of Veteran Affairs (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 PEB combined the bilateral foot pain conditions as a single unfitting condition rated as 5099-5022 (analogous to periostitis) at 0%. The PEB may have relied on AR 635.40 (B.24 f.) and/or the USAPDA pain policy for not applying separately compensable VASRD codes. The Board must apply separate codes and ratings in its recommendations if compensable ratings for each condition are achieved IAW VASRD §4.71a. If the Board judges that two or more separate ratings are warranted in such cases, however, it must satisfy the requirement that each ‘unbundled’ condition was unfitting in and of itself. Thus the Board must exercise the prerogative of separate fitness recommendations in this circumstance, with the caveat that its recommendations may not produce a lower combined rating than that of the PEB.

Bilateral Foot Pain Secondary To Metatarsal Stress Reactions. The narrative summary (NARSUM) notes that the CI presented during Basic Training due to right foot pain. She was found to have a 3rd metatarsal stress fracture documented by bone scan in July 2000. She was treated, the symptoms resolved, and she returned to full duty. The CI had recurrent right foot pain and X-ray 7 December 2000 showed a healing stress fracture and a mild bunion deformity. She was given a profile and medication. The CI then returned with left foot pain and was diagnosed by bone scan in June 2001 to have another metatarsal stress fracture; she was again treated. She continued to have bilateral foot pain and in September 2001 bone scans showed the original stress fractures had healed but there was a question of new stress fractures in the second metatarsal of each foot. At the MEB exam 18 June 2002, approximately 8 months prior to separation, the CI reported aching, burning bilateral foot pain that was severe; that was worsened by walking and prolonged standing. The MEB physical exam noted bilateral hallux valgus with bunions and moderate pes planus without any bony tenderness. The CI saw a foot and ankle surgeon 24 October 2002, approximately 4 months prior to separation. On exam he noted bilateral pes planus and hallux valgus with diffuse discomfort on the plantar aspect of both feet. The metatarsal heads were “well balanced” and there was no crepitus with joint range-of-motion (ROM). Sensation and strength were normal. His conclusion was that her bunions might be the cause of her foot pain, but did not recommend surgery noting her symptoms were diffuse and commented that subjective complaints were more pronounced than he would expect. He recommended orthotics and proper footwear, and possibly a rheumatology evaluation. At the VA Compensation and Pension (C&P) exam 18 March 2003, approximately a month after separation, according to the examiner, the CI reported “rather nonspecific pain in the forefoot bilaterally”, that was helped by orthotics. She reported not running or competing in sports and that her feet were uncomfortable when she was walking or standing. On exam there was no soft tissue swelling or palpable deformity of the metatarsals. There was diffuse tenderness to palpation of the forefoot without localization. The C&P examiner stated, “She has pain in the forefoot without clinical evidence of any deformity or pathologic change related to the metatarsals or feet in general. It appears that her symptoms are on the basis of chronic metatarsalgia or forefoot strain without any evidence of obvious disability or functional impairment.”

The Board directs attention to its rating recommendation based on the above evidence. The PEB bundled the bilateral foot pain conditions and rated as one unfitting condition as 5099-5022 (analogous to periostitis) at 0%. The VA rated the right foot pain and the left foot pain separately, each as 5299-5284 (analogous to other foot injury) at 10% (moderate), combined with bilateral factor to 20%. The Board next undertook to unbundle the bilateral foot pain condition. The CI experienced repeat metatarsal stress fractures in both feet. X-rays in February 2002 showed bilateral bunion deformities. Both the right and left foot were treated in physical therapy and provided orthotics. The permanent profile was for chronic bilateral foot pain. The commander’s statement did not mention a specific condition but indicated that the CI’s permanent profile of no running or jumping, walk, swim or bike at her own pace and distance prevented her from advancing from training to any MOS because she would not be able to meet the minimum physical requirements. The Board concluded that the evidence in the record supports that each foot was separately unfitting. The Board deliberated coding as 5022 or 5284 or 5279 (metatarsalgia). The Board considered that a foot an ankle specialist had opined approximately 3 months prior to separation that the CI’s discomfort may be coming from her bunions, but did not recommend surgery, but proper footwear and orthotics instead; the C&P examiner approximately a month post separation summarized that the described pain in her forefoot was without any evidence of deformity or pathologic changes in her metatarsals or feet and was without evidence of obvious disability or functional impairment. Both the foot and ankle specialist and the C&P examiner commented that the foot pain was not able to be localized. The Board deliberated on whether there was support in the evidence available to meet the 10% disability rating under 5022, 5284, or 5279 for either one or both feet and concluded that there was not. Therefore, having unbundled the bilateral foot pain condition the Board found that there was no benefit to the CI. 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 foot pain 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. As discussed above, PEB reliance on AR 635.40 (B.24 f.) for rating the bilateral foot pain condition may have been operant in this case and the condition was adjudicated independently of that policy by the Board. In the matter of the bilateral foot pain condition, the Board unanimously recommends no change in the PEB adjudication.



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 Foot Pain Condition 5099-5022 0%
COMBINED
 0%


The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20120817, w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans’ Affairs Treatment Record




        
         Physical Disability Board of Review


 SFMR-RB                                                                         


MEMORANDUM FOR Commander, US Army Physical Disability Agency
(TAPD-ZB ),

SUBJECT: Department of Defense Physical Disability Board of Review Recommendation for AR20130009110 (PD201201495)

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                                                 
                                                      (Army Review Boards)

CF:
( ) DoD PDBR
( ) DVA

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