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AF | PDBR | CY2013 | PD-2013-02704
Original file (PD-2013-02704.rtf) Auto-classification: Approved
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXX    CASE: PD-2013-02704
BRANCH OF SERVICE: Army  BOARD DATE: 20140514
SEPARATION DATE: 20060523


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was a Reserve SPC/E-4 (46R/Public Affairs Broadcast Specialist) medically separated for chronic stress fractures of both heels while in basic training. The CI started having pain to his heels in November 2005, within the first month of basic training. He was treated with medication, crutch ambulation and decreased activity, but continued to have pain. He was referred to podiatry where he was treated with casting and a Cam walker with no resolution. The bilateral stress fractures of both heels could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty. His profile allowed for an alternate aerobic event to satisfy physical fitness standards. He was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB). “Stress fractures to heels” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. No other conditions were submitted by the MEB. The Informal PEB adjudicated chronic stress fractures, both heels as a combined single unfitting condition, rated 10%, citing criteria of the US Army Physical Disability Agency (USAPDA) pain policy. The CI made no appeals and was medically separated.


CI CONTENTION: The CI listed “Neuropathy, Depression, feet & leg pain, Anxiety, heels have cracks, grand mal seizures, difficulty walking.”


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 stress fracture condition is addressed below; and, includes “feet pain” and “difficulty walking” as related to the unfitting condition. No additional conditions are within the DoDI 6040.44 defined purview of the Board. The neuropathy, depression, anxiety, heel cracks, grand mal seizures listed in the contention were not identified by the PEB and thus are not 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 20060509
 VA - (5.5 Mos. Post-Separation)
Condition
 Code Rating Condition Code Rating Exam
Chronic Stress Fractures, Both Heels 5099-5003 10% Residuals, Stress Fracture, Left Heel 5284 10% 20061108
Residuals, Stress Fracture, Right Heel 5284 10% 20061108
No Additional MEB/PEB Entries
 Other x 1
Rating: 10%
 Combined Rating: 20%
Derived from VA Rating Decision (VA RD ) dated 200 70129 ( most proximate to date of separation [ DOS ] ).



ANALYSIS SUMMARY:

Chronic Stress Fractures, Both Heels. The CI’s service treatment record indicated that he noted pain in the heels in November 2005 while undergoing basic training. Treatment with anti-inflammatory medication, crutches and decreased activity failed to resolve the pain in the heels. In November 2005, casts were applied by podiatry with no improvement nor was there pain resolution with ankle braces, orthotics and a Cam walker. An X-ray of the left foot on 21 November 2005 noted “that there is some minimal sclerosis of the posterior aspect of the left calcaneus which may represent an early stress fracture.” A bone scan dated 6 March 2006 suggested stress fractures of the left medial tibial plateau and both posterior calcanei (heels). A note dated 7 April 2006 indicated stress fractures to the heels and eczema to the feet. The narrative summary (NARSUM) dated 7 April 2006 noted a “stress fracture line was seen through the left calcaneus, while a bone scan demonstrated significant effect at both heels, indicative of stress fracture[s] to [the] heels.” A podiatric examination demonstrated “no edema, slight erythema, rash to foot, and no cellulitis.” Pain was rated at 5/10, frequent and moderate. He had been treated for approximately 5 months with no long-term relief and was limited from doing pushups, sit-ups or the bike. A temporary L3 profile was granted on 17 April 2006 that precluded unlimited running, walking, biking, and swimming, but the CI could run, walk or swim at his own pace and use “shoe gear of comfort.” A permanent U3 profile was approved on 24 April 2006 that prohibited unlimited running, carrying and moving with a fighting load, or wearing of a Kevlar helmet. The Informal PEB convened on 9 May 2006 found the CI unfit for chronic stress fractures, both heels that did not respond to prolonged conservative treatment and the CI was unable to complete basic training. He was rated 10% for residual pain–frequent, slight under code 5099-5003.

The VA Compensation and Pension exam performed on 8 November 2006, 5.5 months after separation, was not available for review, but was extracted from the VA rating determination dated 29 January 2007 as tenderness to each heel with a normal gait and no radiographic abnormalities.
Ankle ROM
(Degrees)		 MEB ~ 1.5 Mo. Pre-Sep
(20060407)
VA C&P ~ 5.5 Mo. Post-Sep
(20061108) per VARD
Left Right Left Right
Dorsiflexion (20 Normal) 30 (20) 30 (20) - -
Plantar Flexion (45) 30 30 - -
Subtalar joint inversion 30 30
Subtalar joint eversion 10 10
Comment Left heel stress fracture ;
Pain in the ROM		 Right heel stress fracture
Pain in the ROM		 Tender heel Tender heel
§4.71a Rating 10%* 10%* 10% 10%
* PEB awarded a single 10% for combined condition

The Board directs attention to its rating recommendation based on the above evidence. The PEB applied the analogous 5099-5003 to rate the CI’s pain since a compensable range-of-motion limitation was not an option for coding purposes. The CI’s left and right ankles each had X-ray/bone scan abnormalities and limitation of motion on plantar flexion with pain. A rating of 10% should be applied “for each such major joint . . .affected by limitation of motion, to be combined, not added under code [5099-]5003, or with application of VASRD §4.59 (painful motion).” Therefore, the appropriate rating under code 5099-5003 to be applied is 10% for each foot. The Board considered alternative rating under code 5284 foot injuries, other, similar to the VA coding and rating. However, there was insufficient evidence to support higher than a 10% rating for either foot condition. Rating under 5284 could not be additive to the 10% 5099-5003 ratings and therefore offered no advantage to the CI. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt) and §4.59 (painful motion), the Board recommends a disability rating of 10% for the chronic stress fractures, of the right coded 5099-5003 and 10% for the left heel condition heel with the same coding.


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 the USAPDA pain policy for rating the feet was operant in this case and the condition was adjudicated independently of that policy by the Board. In the matter of the chronic stress fractures, both heels condition, the Board unanimously recommends a disability rating of 10% coded 5099-5003 IAW VASRD §4.71a for left foot and 10% coded 5099-5003 for the right foot IAW§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
Chronic Stress Fractures, Both Heels Condition-Left Foot 5099-5003 10%
Chronic Stress Fractures, Both Heels Condition-Right Foot 5099-5003 10%
COMBINED (w/ BLF) 20%



The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20131218, 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, AR20150004692 (PD201302704)
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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