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AF | PDBR | CY2014 | PD-2014-02866
Original file (PD-2014-02866.rtf) Auto-classification: Denied
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXX    CASE: PD-2014-02866
BRANCH OF SERVICE: Army  BOARD DATE: 20141016
SEPARATION DATE: 20080411


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an activated National Guard PV2/E-2 (Basic Trainee) medically separated for bilateral calcaneal stress fractures. 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 condition, characterized as “bilateral calcaneal stress fractures” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. No other conditions were submitted by the MEB. The Informal PEB adjudicated her stress fractures as unfitting, 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 elaborated no specific contention in her application.


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 calcaneal stress fractures are addressed below. In addition, the CI was notified by the Service that his case qualifies for review of his mental health (MH) condition in accordance with the Secretary of Defense directive for a comprehensive review of Service members who were referred to a disability evaluation process between 11 September 2001 and 30 April 2012, and whose MH diagnoses were unfavorably changed or eliminated during that process. In response to said notification, it is presumed that the CI has elected review by this Board for the MH condition. Accordingly, the case file was reviewed regarding unfavorable diagnosis change, fitness determination, applicability of VASRD §4.129, and rating (via §4.129 or §4.130 as appropriate) of the MH condition adjudicated as not unfitting. 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 20080227
 VA - (~4 Mos. Pre/Post-Separation)
Condition
 Code Rating Condition Code Rating Exam
Bilateral calcaneal stress fractures… 5099-5003 10% Chronic Strain of the Left Ankle 5271 10% 20080827
Chronic Strain of the Right Ankle 5271 10% 20080827
Bilateral Pes Planus with Calcaneal Stress Fractures 5276 10% 20080827
Mental Health Not Addressed PTSD NSC
Other x 0 (Not in Scope)
 Other x 0 20080827
Rating: 10%
 Combined: 30%
Derived from VA Rating Decision (VA RD ) dated 200 81201 ( most proximate to date of separation [ DOS ] ).


ANALYSIS SUMMARY:

Bilateral Calcaneal Stress Fractures. In the narrative summary (NARSUM) dated 14 January 2008, the CI reported her bilateral heel pain began in her fourth week of basic training. The bone scan dated 7 August 2007 revealed stress related changes of the bilateral talar domes and bilateral calcaneal stress fractures. The CI was referred to physical therapy and treated with vitamin supplement (Ca+vitD). Treatment records were scarce. Physical therapy consisted of stretches, using the bike and treadmill. The medication profile recorded prescriptions for anti-inflammatory medication; however, treatment notes were absent. At the NARSUM exam, the CI denied a trauma history and indicated she thought her condition was the result of running, jumping, marching, and carrying a heavy rucksack. Her pain level intensity was reported at 7/10, bilateral feet. The CI noted she used arch supports, heel cups, crutches and soft shoes and “she does not feel like she is improving and not be able to ever pass her requirements.” Physical examination of the feet recorded tenderness to palpation of bilateral calcaneus, Achilles and plantar fascial band without evidence of inflammation. The CI was unable to perform the toe raise or heel walk without pain. She had pain on range-of-motion of the ankle joint and of the metatarsophalangeal (toes) joint. The physician noted the musculoskeletal exam was significant for a “flexible pes planus foot type;” and because of the condition she was not capable of performing her military duties. She was not a surgical candidate. Radiographs dated 27 August 2008, revealed no significant pathology of the left foot but noted “Probable pes planus.” The CI’s profile allowed unlimited biking, swimming and body weight training. She could walk at her own pace but was restricted from running.

At the VA Compensation and Pension (C&P) evaluation performed on 27 August 2008, approximately 4 months post-separation, the CI reported she could not stand for longer than 5 minutes and walking was limited to 10 minutes. She took anti-inflammatory medication that did relieve her pain. She had resting pain and pain during activity. Physical examination noted a stiff gait and the absence of assistive device for ambulation. Foot examination revealed absence of abnormal weight bearing or breakdown callouses or any unusual shoe wear pattern. There was no evidence of inflammation, vascular compromise, weakness or muscle atrophy on examination of bilateral feet. The physician diagnosed bilateral calcaneal stress fractures with residual pain and objective finding of tenderness. Pes planus was also diagnosed.

The Board directs attention to its rating recommendation based on the above evidence. The PEB combined the foot condition and rated the condition analogously coded 5099-5003 for pain at 10%, for slight/frequent pain. The VA rated the condition of pes planus with calcaneal stress fractures at 10%, coded 5276. The Board first considered if each foot could be reasonably justified as separately unfitting. The Board noted there were no entries in the treatment record that separated the foot, nor any that considered one more symptomatic than the other. The Board determined the record in evidence did not reasonably support that either foot were separately unfitting; however, taken in combination, the condition was unfitting. The Board agreed separate ratings were not supported by the evidence at hand. The higher rating of 20% under code 5003 required X-ray evidence of involvement of two or more major joints or two or more minor joint groups, with occasional incapacitating exacerbations, which was not supported by the evidence. The Board considered code 5276. A higher evaluation of 20% under code 5276, required objective evidence of marked deformity (pronation, abduction, etc.), pain on manipulation and use accentuated; indication of swelling on use and characteristic callosities, none of which was supported by the evidence at hand. The Board considered the 5284 (other foot injuries); however, there was insufficient evidence to support the higher rating of 20% for moderately severe impairment. Thereupon, after due deliberation, considering all of the evidence and mindful of the VA Schedule for Rating Disabilities (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 condition.
Contended PEB Conditions. The Board’s main charge is to assess the fairness of the PEB’s determination that a MH condition was not unfitting. The Board’s threshold for countering fitness determinations is higher than the VASRD §4.3 standard used for its rating recommendations, but remains adherent to the DoDI 6040.44 “fair and equitable” standard. The Board first reviewed the records for evidence of inappropriate changes in diagnosis of the MH condition during processing through the Disability Evaluation System (DES). The evidence of the available records show no MH diagnosis was rendered during the DES. The Board determined that no MH diagnoses were changed to the applicant’s possible disadvantage in the disability evaluation. This applicant therefore did not appear to meet the inclusion criteria in the Terms of Reference of the MH Review Project. The available treatment records demonstrated no evidence of a MH diagnosis prior to separation. There were no recorded MH symptoms within the available treatment record. There was no evidence of prescriptions for psychotropic medications in the medication profile. The Board noted the CI underwent a VA C&P mental evaluation and reported she had been sexually assaulted. The VARD of December 2008 denied the claim and noted the service treatment records showed no complaints of, treatment for, or diagnosis of posttraumatic stress disorder (PTSD). The VA requested the CI to complete a form, “Statement in Support of Claim for Service Connection for PTSD Secondary to Personal Trauma” with specific stressor detail and/or medical evidence of an in-service stressor (sexual assault) that occurred during service. The CI did not respond. The 2013 VARD noted the claim for PTSD was still denied and that the CI had not provided the necessary evidence to adjudicate the case. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded there was no unfitting MH condition at the time of separation.


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 DoDI 1332.39 for rating bilateral calcaneal stress fractures was operant in this case and the condition was adjudicated independently of that policy/instruction by the Board. In the matter of the bilateral calcaneal stress fracture condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication. In the matter of the contended MH condition, the Board unanimously agrees that it cannot recommend it for additional disability rating. 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.
The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20130426, 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 XXXXXXXXXXXXXXX, AR20150010997 (PD201402866)


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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