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AF | PDBR | CY2013 | PD-2013-02368
Original file (PD-2013-02368.rtf) Auto-classification: Approved
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXX     CASE : PD -20 13 - 0 2368
BRANCH OF SERVICE: Army   BOARD DATE: 201 4 0805
Separation Date: 20050504


SUMMARY OF CASE : Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty PV2/E-2 (88M/Motor Transport Operator) medically separated for chronic bilateral foot pain. The condition could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty or satisfy physical fitness standards. She was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB). The MEB forwarded “left talus and right calcaneus stress fractures” to the Physical Evaluation Board (PEB) IAW AR 40-501. No other conditions were submitted by the MEB. The PEB adjudicated “chronic bilateral foot pain” as unfitting, rated 0% with likely application of the VA Schedule for Rating Disabilities (VASRD). The CI made no appeals and was medically separated.


CI CONTENTION : The CI made a lengthy contention via separate letter attached to her application. Besides her unfitting bilateral foot condition, she specifically cited her “toes”, “ankles”, and “calves” in the letter. Her complete submission, with attachments is at Exhibit A.


 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 bilateral 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.

The Board acknowledges the CI’s information regarding the significant impairment with which her service-connected condition continues to burden her; but, must emphasize that the Disability Evaluation System has neither the role nor the authority to compensate members for anticipated future severity or potential complications of conditions resulting in medical separation. That role and authority is granted by Congress to the Department of Veterans Affairs, operating under a different set of laws. Post-separation evidence is probative to the Board’s recommendations only to the extent that it reasonably reflects the disability at the time of separation.


RATING COMPARISON :

Service IPEB – Dated 20050421
 VA - (7 Mos. Post-Separation)
Condition
 Code Rating Condition Code Rating Exam
Chronic Bilateral Foot Pain 5099-5022 0% Stress Fractures Left Talus 5284 10% 20051202
Stress Fractures Right Calcaneus 5284 10% 20051202
No Additional MEB/PEB Conditions
 Other x0 20051202
Combined: 0%
 Combined: 20%
Derived from VA Rating Decision (VARD) dated 20060213 (most proximate to date of separation [DOS])
 VARD 20080424 continued Left Talus and Right Calcaneus Stress Fracture disabilities at 10% ratings each, effective 20050505.
ANALYSIS SUMMARY : The PEB rated the c hronic b ilateral f oot p ain condition under the single analogous code 5099-5022 Periostitis code. This coding approach is countenanced by AR 635-40 (B.24 f.), but IAW DoDI 6040.44 the Board must apply only VASRD guidance to its recommendation. The Board must therefore apply separate codes and ratings in its recommendations if compensable ratings for each joint 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 reasonably justified as unfitting in and of itself, with the caveat that the final recommendation may not produce a lower combined rating than that of the PEB.

Chronic Bilateral Foot Pain Condition . The CI was initially seen for bilateral heel ( calcaneal) pain in the right foot greater than left foot in Acute Medicine . The examiner documented pain in the right foot worse that the left foot, and diagnosed bilateral heel pain. The CI was prescribed power step cups shoe prosthetics, advised to wear soft shoes and start a non-st eroidal anti-inflammatory drug 3 times daily for 10 days. The initial bilateral heel X - ray performed on 27   January 2005 which was normal, a repeat X - ray performed 10 days later was also normal. A b one scan revealed stress fractures in the left talus and right calcaneus . The CI was given a s ick c all slip for bilateral calcaneal stress fractures. The examiner recommended a 30 - day convalescent leave to rest, stretch , ice and calcium supplements along with a 2 week rest, then a walking program. The CI was re - evaluated by physical therapy ( PT ) after the convalescent period and continued to report bone pain in the right foot a nd hee l and pain in the left heel. The PT physical exam findings are summarized in the chart below . The CI was given a permanent L3 Profile for bilateral foot stress fracture s. The MEB n arrative s ummary (NARSUM) exam approximately a month prior to separation documented that the CI had a “poor prognosis for completion of basic training secondary to limited motivation to compete PT and noncompliance with medical care . ” She reported bilateral foot pain that averaged 3/10 at rest and at a 5/10 with prolonged walking, especially when wearing boots. The examiner diagnosed left talus and right calcaneal stress fractures with resulted in interference with satisfactory performance of duty. The MEB NARSUM physical exam findings are summarized in the chart below . A right foot X -ray was normal. The VA Compensation and Pension (C&P) exam approximately 7 months after separation documented that walking a long distance, wearing heels or standing for a long period of time caused flare ups which would last 2 to 3 days with a pain level at 5-6/10 . She did not require orthotics, crutches or canes to assist with ambulation. The C&P physical exam findings are summarized in the chart below .

There were three evaluations in evidence which the Board weighed in arriving at its rating recommendation; as summarized in the following chart :

Ankle ROM
(Degrees)		 PT 3 Mo s . P re -Sep MEB 1 Mo. P re -Sep VA C&P 7 Mo s . Post-Sep
Left Right Left Right Left Right
Dorsiflexion (20) “ Normal ” “ FROM ” “ No limitation of motion ”
Plantar Flexion (45)
Comment Pos. t ender ness N avicular tuberosity Normal g ait & pulses; No swelling or ecchymosis Normal gait; Pos. t enderness both heels; Painful heel standing
Pos. t enderness anterior aspect of foot Pos. t enderness right heel
Pos. tenderness both heels; Normal gait
§4.71a Rating 10% 10% 10% (PEB 0%) 10% (PEB 0%) 10% 10%
invalid font number 31502
The Board directs attenti on to its rating recommendation based on the above evidence . The PEB coded the c hronic b ilateral f oot p ain condition as 5099 analogous to 5022 ( p eriostitis ), rated at 0%. The VA coded the s tress f ractures l eft t alus condition as 528 4 ( f oot injuries , other ), rated at 10% m oderate. The VA also coded the s tress f ractures r ight c alcaneus as 5284 , rated at 10% m oderate. Based on abnormal bone scan findings in each foot and the L3 profile for bilateral stress fractures, Board members agree was that the evidence supports that each foot was reasonably justified as separately unfitting at the time of separation ; therefore , separate disability rating s will be recommended . The VASRD does not contain a code specific for stress fractures; therefore, analogous coding is appropriate. The PEB used 5022 which is rated under 5003 ( degenerative arthritis ) while to VA used code 5284. The Board considered each coding and rating scheme and agreed that use of either code would result in a 10% rating for each foot , as applied by the VA. Considering all of the evidence and mindful of VASRD §4.3 r easonable doubt and the Board recommends a disability rating of 10% coded 5099-5022 IAW VASRD §4.71a for the s tress f ractures r ight c alcaneus condition and 10% coded 5099-5022 IAW VASRD §4.71a for the s tress f ractures l eft t alus 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. 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 c hronic b ilateral f oot p ain condition, the Board by a majority vote recommends that each joint be separately adjudicated as follows: an unfitting s tress f ractures r ight c alcaneus condition coded 5099-50 22 and an unfitting s tress f ractures l eft t alus also coded 5099-5003 and separately rated at 10% for each foot IAW VASRD §4.71a. The single voter of dissent did not elect to submit a minority opinion. 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 her prior medical separation:

UNFITTING CONDITION VASRD CODE RATING
Stress Fractures Right Calcaneus 5099-5022 1 0%
Stress Fractures Left Talus 5099-5022 10%
COMBINED (w/ BLF) 2 0%
invalid font number 31502

The following documentary evidence was considered:
Exhibit A. DD Form 294, dated 20 131111 , w/atchs
Exhib it 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, AR20150002552 (PD201302368)
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

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