RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD1300694
BRANCH OF SERVICE:  Army	BOARD DATE:  20140131
SEPARATION DATE:  20040116

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a Reserve SFC/E-7 (77W/Water Treatment Specialist) medically separated for chronic bilateral plantar fasciitis.  The CI suffered from chronic bilateral foot pain over the course of her career.  She underwent a bilateral plantar fasciotomy, and despite follow on treatment, her condition did not improve adequately 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 bilateral foot condition, characterized as “chronic bilateral plantar fasciitis”, was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  With respect to the CI’s mental health (MH) condition, she was evaluated in July 2003 after returning from a deployment to Kuwait.  The CI was diagnosed by an Army Psychologist with anxiety/depressive disorder, not otherwise specified (NOS).  She also sought treatment from the VA where she was diagnosed with posttraumatic stress disorder (PTSD) and major depressive disorder (MDD).  The MEB did not identify any MH condition.  The only condition forwarded to and adjudicated by the PEB was “chronic bilateral plantar fasciitis” which was found to be unfitting and rated 0% with likely application of the VA Schedule for Rating Disabilities (VASRD).  The CI made no appeals and was transferred to the Inactive Reserve after her release from active duty and waiving severance pay for the 0% disability rating.

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.  In addition, the CI was notified by the Army that her case may eligible for review of the military disability evaluation of her MH condition in accordance with 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 mental health diagnoses were changed during that process.  The CI is eligible for PDBR review of her conditions evaluated by the PEB and elected review by the PDBR.  As such, the rating for the unfitting bilateral foot condition is addressed below.  In accordance with Secretary of Defense directive for a comprehensive review of MH diagnoses that were changed during the Disability Evaluation System (DES) process, the applicant’s case was reviewed with regard to the MH diagnosis change, fitness determination, and rating of unfitting MH diagnoses in accordance with the VASRD §4.129 and §4.130.  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 20031202	VA – based on Service Treatment Record (STR)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Bilateral Plantar Fasciitis	5399-5310	0%	Bilateral Foot Condition, Plantar Fasciitis	5299-5279	10%	STR	
No Additional MEB/PEB Entries	Other x18	20040624	
Combined:  0%	Combined:  50%	
Derived from VA Rating Decision (VARD) dated 20040823 (most proximate to date of separation [DOS])
*VARD 20100202 granted 100% for DC 5299-5284 (code change from 5299-5279) from 20040920; then 30% from 20041101, combined 60% from 20041101.  VARD 2011116 granted 50% for DC 9411 (PTSD) from 20100730, combined 80% from 20100730. 

ANALYSIS SUMMARY:  IAW DoDI 6040.44, the Board’s authority is limited to making recommendations on correcting disability determinations.  The Board’s role is thus confined to the review of medical records and all evidence at hand to assess the fairness of PEB rating determinations, compared to VASRD standards, based on ratable severity at the time of separation and to review those fitness determinations within its scope (as elaborated above) consistent with performance-based criteria in evidence at separation.

The PEB combined the right and left foot plantar fasciitis under a single disability rating, coded analogously to 5310.  VASRD §4.73 requires separate ratings for separately compensable muscle group injuries.  The Board must follow suit (IAW DoDI 6040.44) if the PEB combined adjudication is not compliant with the latter stipulation, provided that each “unbundled” condition can be reasonably justified as separately unfitting in order to remain eligible for service rating.  If the members judge that separately ratable conditions are justified by performance-based fitness criteria and indicated IAW VASRD §4.7 (higher of two evaluations), separate ratings are recommended; with the stipulation that the result may not be lower than the overall combined rating from the PEB.  The Board’s initial charge in this case was therefore directed at determining if the PEB’s combined adjudication was justified in lieu of separate ratings.

The CI had identical conditions in both feet, both feet were treated identically and both feet responded in the same way to treatment.  The permanent profile designated “chronic bilateral plantar fasciitis” as the limiting condition and the commander’s statement only mentions “physical impairments” as duty limiting.  Board consensus was that it is reasonably justified that either foot would have been separately unfitting and therefore warrants a separate rating.  Since both feet were essentially the same and all documentation refers to a “bilateral” condition, they will be discussed together and the rating recommendation will apply separately to each foot.

Bilateral Plantar Fasciitis.  The CI had a long history of bilateral foot pain finally diagnosed as chronic bilateral fasciitis in 2001.  She was treated with splinting, orthotics, non-steroidal anti-inflammatory drugs, as well as duty modification by podiatry without a decrease in her pain.  She underwent a surgical procedure, open plantar fasciotomy, on both feet (the right in October 2002 then the left foot in November 2002).  A STR note in December 2002 documented good relief of pain after the procedure.  The CI was mobilized and deployed to Kuwait in March 2003.  By June 2003, her bilateral foot pain returned and was not controlled by narcotic medication so she was med-evacuated back to the states for treatment.  She had a normal plain film X-ray of both feet at that time.  Her foot pain continued despite treatment and she was given a permanent profile in October 2003 and entered into the DES.  In the narrative summary (NARSUM) prepared 5 months prior to separation, the podiatrist wrote the following passages:

“I have followed the patient and treatments include but are not limited to orthotic devices, Cam Walkers, oral anti-inflammatory medications, physical therapy, corticosteroid injection treatment, weight-bearing casts, night splints and numerous temporary profiles.  Her condition did not improve.  I felt she was not a candidate for further surgical management at this time, considering that she had plantar fascial releases approximately two years ago.  Over the course of many months there was no change in the condition and she states that she is able to do most of her work however; she has discomfort with any prolonged standing in military shoe gear, physical training and any lifting of heavy objects.”

The physical exam documented pain with palpation along the plantar fascia with no swelling or redness.  There were no ankle abnormalities and normal strength of both feet.  The diagnosis was chronic bilateral plantar fasciitis, with the intensity of pain as “slight” and “frequent.”  The date of onset was noted to be 1985 (during active duty in Korea) and it did not exist prior to service.  The MEB physical exam accomplished 6 months prior to separation confirmed the findings noted above.  At the VA Compensation and Pension (C&P) exam performed 13 months after separation, the CI reported she was doing significantly better prior to her deployment but during her deployment her pain had gradually worsened.  She stated the pain was greatest at night, had some difficulty walking and had diffused achy pain on the plantar aspect and dorsum of the feet.  The physical exam revealed that she presented in 3D boots, which were removed.  She had an antalgic gait bilaterally but had normal strength, reflexes and vascular function of both feet.  She had well-healed incisions from previous plantar fascia releases and normal ankle range-of-motion.  She had no pain over the insertion of the plantar fascia and no significant heel pain as long as she was distracted during the exam; if allowed to watch the examiner she winced when ever palpated.  She had no instability about her ankles or hind foot and no callosities.  The VA examiner’s assessment was the following:

Bilateral foot pain currently being treated for bilateral plantar fasciitis although she is minimally tender at her plantar fascia origin.  She does have significant pes planus deformity bilaterally but no significant posterior foot pain.

The Board directs attention to its rating recommendation based on the above evidence.  In adjudicating the chronic bilateral plantar fasciitis, the PEB applied the analogous VASRD code of 5399-5310, Group X muscle injury, and rated it 0% for “slight.”  The VA initially coded it 5299-5279, anterior metatarsalgia, and rated it 10% which is the only rating option under the 5279 code.  Later, the code was changed to 5299-5284, other foot injuries, and rated it 30% for “severe.”  The board surmised the PEB’s use of code 5310 is most appropriate as it represents the best coding option as the Group X muscle code includes “Other important plantar structures: Plantar aponeurosis, long plantar and calcaneonavicular ligament, tendons of posterior tibial, peroneus longus, and long flexors of great and little toes” in its rating guidelines as copied below:

5310 Group X. Function: Movements of forefoot and toes; propulsion thrust in walking. Intrinsic muscles of the foot: Plantar: (1) Flexor digitorum brevis; (2) abductor hallucis; (3) abductor digiti minimi; (4) quadratus plantae; (5) lumbricales; (6) flexor hallucis brevis; (7) adductor hallucis; (8) flexor digiti minimi brevis; (9) dorsal and plantar interossei. Other important plantar structures: Plantar aponeurosis, long plantar and calcaneonavicular ligament, tendons of posterior tibial, peroneus longus, and long flexors of great and little toes.
Severe.............................................................30
Moderately Severe..........................................20
Moderate........................................................10
Slight................................................................ 0

The Board notes that the rating options are subjective in nature and consensus was that the CI’s impairment due to plantar fasciitis did not exceed the “slight” level as documented by the NARSUM examiner.  The NARSUM and the C&P exam contain language that the CI was functional but had pain in both feet only with prolonged activity.  A C&P exam for another condition performed 5 months after separation documented a normal gait and heel/toe walking.  Eight months later, her C&P exam demonstrated an antalgic gait with some pain on palpation of her feet but was otherwise normal.  The C&P examiner suggested a psychological component to her pain.  Separately rating the CI’s right and left plantar fasciitis as “slight”, the 0% rating level would result in a 0% combined rating and confer no benefit to the CI.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), a majority of the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the chronic bilateral plantar fasciitis condition.

MHR Condition.  The Board determined that it was appropriate that no MH diagnosis was identified by the MEB or adjudicated by the PEB and therefore, no MH diagnoses was changed to the applicant's possible disadvantage during the DES process.  This applicant therefore did not meet the inclusion criteria in the Terms of Reference of the MH Review Project.  The CI had documented drug abuse and depression while in Service in 1984 and again in 2002.  Also in 2002, a VA MH provider diagnosed her with a single episode of major depression and “rule-out” PTSD due to the CI’s being sexually abused as a child.  The next MH related encounters occurred after her return from deployment.  She complained of sleep impairment due to her foot pain and worrying/anxiety which was deployment related.  On the MEB medical history form (DD Form 2708-1) completed 6 months prior to separation, the CI indicated “I can’t sleep good because of my foot pain & hands” and “I get depressed very easy and I worried about everything.”  A medical statement prepared 2 months prior to separation contained the following statements:

“She was experiencing problems sleeping since her return from Kuwait in early July.  She couldn't sleep because she had pain in her hands and feet and she was also worried about her unit back in Kuwait.  She was also experiencing crying spells, decreased concentration and appetite, irritability, and anxiety.  She was also experiencing some difficulties in her interpersonal relationships.  Her anxiety signs and symptoms had increased to panic at times and she was worrying about her pending transition back to civilian life.”

The Board’s threshold for recommending a condition as “unfitting” is higher than the VASRD §4.3 (reasonable doubt) standard used for its rating recommendations, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.  The Board could not find evidence in the commander’s statement or elsewhere in the STR that documented any significant interference of an MH condition with the performance of duties nor were any mental status exam findings which would logically be associated with significant MH disability at the time of separation.  There were no psychiatric hospitalizations for any MH condition prior to separation.  The Board notes that coincident to separation, the CI received treatment in the VA for depression and then over 3 years later, a diagnosis of PTSD was rendered.  The Board agrees that it would be speculation to determine that an unfitting MH condition existed at the time of separation.  After due deliberation in consideration of the preponderance of the evidence, the Board agrees that there is insufficient cause to recommend that an unfitting MH condition be added to the applicant’s DES record and, therefore, no additional disability rating can be recommended.

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 chronic bilateral plantar fasciitis condition and IAW VASRD §4.71a, the Board, by a split 2:1 vote, recommends no change in the PEB adjudication.  The single voter for dissent did not elect to submit a minority opinion.  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 recharacterization of the CI’s disability and separation determination, as follows:

UNFITTING CONDITIONS	VASRD CODE	RATING	
Chronic Bilateral Plantar Fasciitis	5399-5310	0%	
COMBINED	0%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20130528, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

			
SFMR-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 XXXXXXXXXXXXXXXXXX, AR20140007313 (PD201300694)

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