RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXX		BRANCH OF SERVICE: ARMY
CASE NUMBER:  PD0900159		COMPONENT: REGULAR
BOARD DATE: 20090630		SEPARATION DATE: 20061027
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SUMMARY OF CASE:  This covered individual (CI) was an NCO medically separated from the Army in 2006 after 15 years of service.  The medical basis for the separation was a foot condition.  The CI entered the service with bilateral pes planus (flat feet) on his MEPS physical, without waiver.  He began developing bilateral foot pain in 2000, with gradual worsening despite orthotics and conservative treatment.  He was also diagnosed with plantar fasciitis and ultimately placed on a permanent L3 profile, resulting in a medical board.  A podiatrist deemed that his foot condition was not medically acceptable and that surgery would unlikely fit him for continued military service.  He was referred to the PEB and separated at 10% disability for pes planus as his only unfitting condition.
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uiupheld the original finding), and is likewise contending to the PDBR, that other conditions were also medically unacceptable and should have been included in his separation rating.  The other contended conditions include back pain, hypertension (HTN) and depression.  The CI states that his MEB evaluation was incomplete.
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RATING COMPARISON:

Service PEB	VA	
IPEB/FPEB Condition	Code	Rating	Date	Condition	Code	Rating	Exam	
Bilateral Pes Planus. Moderate Left Foot 10%, Mild Right Foot 0%. 	5299 5276	10%	20060828	Bilateral Pes Planus	5276	10%	20070130	
				Chronic Plantar Fasciitis Right	5284	10%	20070130	
				Chronic Plantar Fasciitis Left	5284	10%	20070130	
				Depression	9434	30%	20070130	
				Back Strain with DJD	5237	20%	20070130	
				Hypertension	7101	10%	20070130	
				Other Non-PEB X 7			20070130	
TOTAL Combined:    10%	TOTAL Combined (incl. non-PEB Dxs):   80 %	
(26 additional conditions rated by VA as not service connected)
ANALYSIS SUMMARY:

Foot Rating.  It is apparent from the service treatment record (STR) that the overall disability picture of his foot problem was not severe.  With rare exception, he was noted with a normal gait.  Except for occasional notations of tenderness, foot exams were benign (other than the anatomic pes planus).  The initial VA rating exam likewise noted a normal gait and benign findings except for some mild tenderness over the left ankle.  It was noted that his limitations were pain with prolonged walking, standing, climbing and weight-lifting; and stated that he could walk one mile without rest.  The PEB intent in breaking down the pes planus rating into left and right components is not clear, although the conclusions in doing so are well supported by the Podiatrist in the narrative summary.  A 10% rating under the 5276 code is equally applicable to unilateral or bilateral involvement.  There is a component of EPTS for the pes planus, but no evidence of PEB deduction.  The disparity between PEB and VA overall ratings for the feet stemmed from the VA addition of ratings for plantar fasciitis.  Although the history of plantar fasciitis is present in the MEB exam and narrative summary, no physical signs of active plantar fasciitis are in evidence in the STR.  The VA rating decision for plantar fasciitis notes ‘a current diagnosis’ of symptomatic plantar fasciitis.  The rating exam itself, however, lists plantar fasciitis as #20 of multiple conditions, and documents no physical findings of acute inflammation.

Back Pain.  The CI repeatedly made the point in his appeals that his back pain was secondary to the foot condition (possibly because of posture, although the link is never specified).  The connection is stated in the MEB physical as well, presumably as verbal history from the CI.  There is no documented provider opinion regarding cause and effect in the STR, nor was one made by the C&P examiner.  To the contrary, there is a MEB physiatrist opinion that the back pain was more psychogenic than organic.  There are a few entries in the STR referable to the back complaint, but no evidence of high acuity or frequency.  A normal gait and normal thoracolumbar range-of-motion was specifically noted in one entry.  Although some of the activity limitations noted in fitness data could be interpreted to include the back as well as feet, this would be solely speculative.

Depression.  There is no comprehensive psychiatric evaluation documented in the STR, although there is no indication that an evaluation was pursued by the CI until the MEB process.  The MEB physical notes depression treated by Prozac, and the CI was followed by Behavioral Health during the MEB process.  He was diagnosed as adjustment disorder with depression.  The Behavioral Health provider documented his status and did not recommend a full psychiatric addendum.  This was appealed by the CI and rebutted.  There are no entries in the STR relating depression to fitness, and the VA rating examiner noted that he was not missing work because of depression.  His profiles were always S1.

Hypertension and Other Conditions.  Hypertension was stable and well-controlled for the most part.  There are a few erratic readings in the STR with modest elevations, although cited by the CI as significant.  As is generally the case, no link of hypertension with unfitness is evident.  The CI contends that restless leg syndrome (RLS), which was documented in his sleep study, was attributed to his foot condition.  The pathophysiology of RLS does not support that link, and, regardless, the jump to unfitting would be impossible.  The CI’s additional orthopedic and other conditions are too numerous to discuss individually, but were scrutinized for rating potential and fitness implications by the Action Officer.    None were significant and most would not meet the threshold for PDBR jurisdiction to add as unfitting. 
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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 PDBR 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.  

The Board first reviewed the appropriateness of the PEB coding and rating for the foot condition under the VASRD.  Consideration was given to adding plantar fasciitis ratings as additional unfitting conditions.  This was rejected on the basis that: 1) It is not congruent with the overall disability picture and certainly would not add the degree of additional disability carried by the VASRD ratings; and, 2) There is nothing to indicate that plantar fasciitis was an active diagnosis at the time of separation.  A higher rating under the same code was not supported by the record nor granted by the VA.  No coding change to achieve a higher rating was justified.  The Board unanimously concluded, therefore, that the PEB adjudication for the unfitting condition was appropriate. 

The Board individually considered the CI’s contended additional conditions.  It is noted that only the foot condition was specifically forwarded by the MEB for PEB adjudication of fitness.  All of the conditions, however, were formally addressed by consultation and/or written opinion in response to the CI’s several letters of appeal.  There is no suggestion in the STR that any of the CI’s contended or numerous other co-existent medical issues were overlooked or under-evaluated by the service.  The commander’s letter, provider recommendations regarding fitness and numerous physical profiles in the STR were all confined to limitations imposed only by the foot condition.  

The Board unanimously concluded that there is no justification for finding the back condition, HTN, depression or other diagnoses as additional unfitting conditions for PEB rating.
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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 20090206, w/atchs.
Exhibit B.  Service Treatment Record.
Exhibit C.  Department of Veterans' Affairs Treatment Record.