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AF | PDBR | CY2013 | PD-2013-02791
Original file (PD-2013-02791.rtf) Auto-classification: Denied
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXX     CASE : PD -20 13 - 02791
BRANCH OF SERVICE: Army   BOARD DATE: 201 4 0805
Separation Date: 20070815


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SPC/E-4 (88K/Watercraft Operator) medically separated for a right foot condition. This condition could not be adequately rehabilitated to meet the requirements of his Military Occupational Specialty (MOS) or physical fitness standards, so he was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB). The right foot condition, characterized as “right foot crush injury with persistent pain and recurrent stress fractures,” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. The MEB also identified and forwarded two other conditions (see rating chart below) for PEB adjudication. The PEB adjudicated “crush injury of the right foot…” as unfitting, rated 20%, citing criteria of the VA Schedule for Rating Disabilities (VASRD). The remaining conditions were determined to be not unfitting. The CI made no appeals and was medically separated.


CI CONTENTION : “Crushed foot and use of cane. Use of cane not permitted in the MOS 88K water craft operator and suffering from color deficiency in both eyes.”


 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 right foot condition is addressed below; no additional conditions are within the DoDI 6040.44 defined purview of the Board. The color deficiency in both eyes was not identified by the PEB, so it is not in the scope of this 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 :
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Service PEB – Dated 20070719
 VA - (4 Mos. Post-Separation)
Condition
 Code Rating Condition Code Rating Exam
Crush Injury of the Right Foot 5284 20% Crush Injury, Right Foot 5284 30% 20070928
Right Knee Synovitis Not Unfitting Synovitis, Right Knee 5024 10%
Left Shoulder Impingement Left Shoulder Impingement 5201 10%
No Additional MEB/PEB Entries
 Other x12
Combined: 20%
 Combined: 80%
Derived from VA Rating Decision (VARD) dated 20071206 (most proximate to Date of Separation)


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ANALYSIS SUMMARY : IAW DoDI 6040.44, the Board’s authority is limited to making recommendations on correcting disability determinations. The Board reviews medical records and other available evidence to assess the fairness of PEB rating determinations, using the VASRD standards, based on ratable severity at the time of separation and, to review those fitness determinations within its scope consistent with performance-based criteria in evidence at separation.

Crush Injury of the Right Foot Condition . T he CI sustained a crush injury to his right foot when he dropped a metal plate on his foot while deployed . Physical exam findings were abrasion, ecchymosis, edema and tenderness to palpation (TTP). An X -ray showed a transverse fracture of the second metatarsal on the right foot. The examiner applied a splint to t he right foot, ordered a non-st eroidal anti-inflammatory drug , ice, elevation and an o rthopedics consult. The o rthopedist noted tenderness at the second metatarsal and swelling and confirmed the diagnosis of closed fracture of the second metatarsal. A month later, a p rimary c are examiner noted on that a repeat X -ray showed fractures of the 2nd and 3rd metatarsal with slight displacement. A splint was ordered to be worn for 5 weeks. Throughout this time period of splinting, the CI was placed on a temporary L2 p rofile for fractures of the 2nd and 3rd metatarsals of the right foot. The p rimary c are examiner noted continued right foot soft tissue and bone pain. Physical exam findings were swelling, TTP and pain with motion and TTP to the distal second metatarsal. The CI was medically evacuated to Landstuhl Regional Medical Center (LRMC) as he was no w in a C am walker and required further rehabilitation. He was seen by o rthopedics and p rimary c are who noted numbness and tingling on the right foot, bruising, swelling and pain with stair climbing. The physical exam findings were TTP and discoloration. A repeat X- ray showed displacement of the 2nd and 3rd metatarsal. The CI was m edically evacuated for o rthopedics reevaluation who documented that the pain slowly worsened as activity was increased and now had constant pain. The physical exam findings showed TTP over the dorsum of the foot even with light touch and slight discoloration of the skin. He required a cane to ambulate. He was returned to LRMC for reevaluation and then transferred to CONUS for care. He w as followed by o rthopedics and p rimary c are that documented right foot nonspecific tenderness, abnormal gait and stance, several hyper pigmented regions to the dorsum of the foot and required a cane for ambulation. The o rthopedist noted that a b one s can demonstrated right foot metatarsal stress fractures. Five months prior to separation, t he p hysical t herapist examined the CI and performed the range-of-motion ( ROM s) for the MEB n arrative s ummary (NARSUM) e xam , which are summarized in the chart below . A repeat b one s can demonstrated a possible re - injury with a moderate interval increase in activity within the right metacarpal bases. The CI was given a permanent L3 p rofile for right foot pain, status post crush injury . The MEB NARSUM exam , approximately 2 months prior to separation , documented that after 6 months of casting and returned back to a boot, the CI was started back on a running program , and within 3 months he had a reoccurrence of metatarsal stress fractures. This examiner noted that since that time, t he CI ’s foot had been i mmobilized with slow clinical healing of the stress fractures. He had a pain rating of 2-3/10 with a cane and without a cane the pain rating was 4-5/10 , with chronic pain. The MEB NARSUM physical exam findings are summarized in the chart below . The c ommander’s s tatement noted that the CI was no longer able to perform the Army Physical Fitness Test or other physical requirements of his MOS due to the required use of a cane for ambulation. The VA Compensation and Pension (C&P) exam , approximately 1.5 months after separation , documented right foot constant pain at 9/10 , weakness, stiffness, swelling, heat and redness; pain on standing and walking, periods of flare-ups three times per week with a 10/10 pain lasting 1 to 2 hours. He had daily functional limitations of an inability to stand more than 30 minutes and an inability to walk more than 1 to 2 blocks. The C& P physical exam findings are summarized in the following chart .

There were two goniometric ROM evaluations in evidence, with documentation of additional ratable criteria, which the Board weighed in arriving at its rating recommendation; as summarized in the chart below.

Right Ankle ROM Degrees PT 5. 5 Mo s . Pre-Sep MEB 2 Mo s . Pre-Sep VA C&P 1.50 Mo s . Post-Sep
Dorsiflexion 0-20 5 -- 10 ( 8 )
Plantar Flexion 0-45 15 -- 15
Comment
Pos. antalgic gait; Pos. tenderness, muscle spasms & guarding
 Pos. antalgic gait cane assisted; Pos. persistent swelling & redness; No skin changes; “Good” ROM of ankles Pos. antalgic gait cane assisted ; Pos. tenderness to palpation; Decreased movement of toes of right foot ; Repetitive motion increased ROM; No temperature change; No skin or vascular changes; Normal reflexes and sensation
§4.71a Rating
20% vs 30%
 20% vs 30% 20% vs 30%
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The Board directs attenti on to its rating recommendation based on the above evidence . The P EB coded the c rush i njury of the right f oot condition as 5284 (o ther f oot injuries ) and rated it at 20% - m oderately severe. The VA also coded the r ight f oot c rush i njury condition as 5284 but rated i t 30% - s evere. The Board looked at the exams most proximate to separation, which were the MEB and C&P exams. Both exams document ankle ROM measurements that were consistent with a moderate severe limitation of motion, 2 0% rating. The C&P exam also documented that the CI’s ankle ROM improved with repetitive motion. They both documented an antalgic, cane assisted gait; however, there were no additional physical findings that would be consistent with additional impairment related to reflex sympathetic dystrophy or nerve/muscle impairment. The rating criteria for code 5284 are copied below for the reader’s convenience:

5284 Foot injuries, other:

Severe 30
          Moderately severe 20
 Moderate 10

 Rating under this code entails a judgment call regarding the severity of the impairment as there is no objective rating criteria. Members agreed that a fair threshold for the “ severe ” rating should entail functionally significant muscle, nerve, or severe ROM based impairment encroaching on some occupational tasks. It was concluded that there was not sufficient insufficient evidence in this case that this threshold was met. 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 right foot crush injury 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 rush i njury, r ight f oot condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication. 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.


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The following documentary evidence was considered:
Exhibit A. DD Form 294, dated 20 131218 , 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, AR20150004694 (PD201302791)

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

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