RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXX	CASE:  PD-2013-01817
BRANCH OF SERVICE:  Army	BOARD DATE: 20140710
SEPARATION DATE:  20040917

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SPC/E-4 (15B/Turbine Engine Repair Technician) medically separated for chronic bilateral plantar fasciitis and equinus deformity of feet.  The condition could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty (MOS) or satisfy physical fitness standards.  She was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  The chronic recurrent plantar fasciitis bilaterally and equinus deformity bilaterally conditions, characterized as “fails to meet retention” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also identified and forwarded one other condition.  The Informal PEB adjudicated chronic bilateral plantar fasciitis and equinus deformity as unfitting, rated 0% with likely application of the Veterans Affairs 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:  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 chronic recurrent plantar fasciitis bilaterally and equinus deformity bilaterally conditions are addressed below; no additional conditions are 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 20040524	VA - (1 Mos. Pre-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Bilateral Plantar Fasciitis, and Equinus Deformity	5399-5310	0%	Pes Planus, Equinus Deformity, Achilles and Plantar Spur, S/P Plantar Fascial Release Due To Plantar Fasciitis Involving Right Foot	5299-5284	20%	20040809	
			Pes Planus, Equinus Deformity, Achilles and Plantar Spur, S/P Plantar Fascial Release Due To Plantar Fasciitis Involving Right Foot	5299-5284	20%	20040809	
No Other Items in Scope	Other x 1 (Not in Scope)		
Combined:  0%	Combined:  60%	
Derived from VA Rating Decision (VARD) dated 20050110 (most proximate to date of separation [DOS]).

ANALYSIS SUMMARY:

Chronic Bilateral Plantar Fasciitis and Equinus Deformity.  The PEB combined the unfitting bilateral plantar fasciitis condition for single rating.  The approach by the PEB reflected its judgment that the constellation of conditions was unfitting, and there was no need for separate fitness adjudications or implied adjudication that each condition was separately unfitting.  The Board’s initial charge was to determine if the PEB’s approach of combining conditions under a single rating was justified in lieu of separate ratings.  When considering a separate rating for each condition, the Board considers each bundled condition to be reasonably justified as separately unfitting unless a preponderance of evidence indicates the condition would not cause the member to be referred into the Disability Evaluation System or be found unfit because of physical disability.  When the Board recommends separate fitness recommendations in this circumstance, its recommendations may not produce a lower combined rating than that of the PEB.

According to the podiatry MEB consultation, the CI experienced the onset of foot pain in June 2002, 4 months after entry into military service.  A service treatment record dated 27 June 2002 documents care for left foot pain of 2 weeks duration.  She passed the physical fitness test two mile run (83 points out of a maximum of 100) on 1 August 2002.  A 6 September 2002 clinic entry noted left heel pain for 2 months that was improving.  After arrival to her new duty station in November 2002, she sought care for bilateral foot pain diagnosed as plantar fasciitis (inflammation of thick plantar fascia on bottom of foot that connects the heel to toes and creates the arch often associated strenuous training such as running).  She underwent left foot plantar fascial release surgery in March 2003 (endoscopic; a minimally invasive surgical treatment).  She passed the alternate fitness test walk in 26 August 2003 (72 points out of a maximum of 100 points).  A podiatry clinic note on 4 September 2003 recorded there was marked improvement in the left foot pain.  A 16 September 2003 podiatry record entry notes following the left foot surgery there was “successful resolution of her symptoms.”  The same procedure was performed for the right foot 16 September 2003.  Post-operative notes on 19 September and 2 October indicated satisfactory healing.  The 1 December 2003 aviation clinic encounter recorded complaint of persisting left greater than right foot pain.  The CI reported that walking was slow but tolerable for short distances.  Her right foot was still in a “cam walker” post-operative.  The physician initiated an MEB due to the fact that duty limitations had been in place for more than one year.  The 10 December 2003 commander’s statement indicated that in her degraded physical condition, the CI was unable to perform the duties of her MOS and should be evaluated for reclassification or separation.  At the 18 February 2004 MEB consultation by podiatry, the CI complained of persistent painful heels, in spite of conservative nonsurgical measures and bilateral plantar fascial releases.  The CI complained of a continued burning and throbbing sensation to the plantar heels and bottoms of her feet.  The pain occurred with prolonged standing and at night.  On examination there was tenderness to palpation along the bilateral plantar fascia.  The feet and ankles showed no edema, ecchymosis or open lesions.  Ankle dorsiflexion was 0 degrees bilaterally due to tight Achilles tendons (heel cords).  The diagnoses were listed as chronic recurrent plantar fasciitis bilaterally and equinus deformity (lack of dorsiflexion at the ankle due to tightness of the Achilles tendon) bilaterally.  Podiatry concluded that the CI’s podiatric condition failed to meet retention criteria and recommended that she should be referred to the PEB for further disposition.

In the 11 March 2004 MEB narrative summary examination the CI complained of continued pain in the plantar aspects of both feet.  She denied significant relief from surgical procedures and conservative management.  The CI reported modest pain relief with rest, elevation, nonsteroidal anti-inflammatory drugs (NSAIDs) and an anti-convulsant drug used for neuropathic pain.  She complained of constant, sharp, throbbing, burning, 4-5/10 pain with exacerbations to 8-9/10 with activity (running, jumping, marching, prolonged standing, weight bearing).  Physical examination findings were documented from the 18 February 2004 MEB consultation by podiatry.  On 29 April 2004, the CI was placed on an L3 permanent profile.  The 4 May 2004 MEB referred chronic recurrent plantar fasciitis and equinus deformity bilaterally as not meeting retention standards.  

At the 9 August 2004 VA Compensation and Pension (C&P) examination, a month prior to separation, the CI reported the onset of plantar fascia discomfort in June 2002 that persisted despite treatment.  The CI indicated that she was able to stand for 4-6 hours using over the counter orthopedic shoe/appliance (Z-coil pain relief footwear).  The CI reported she was only able to stand for about an hour without Z-coil shoes and was no longer able to run or participate in sports.  She indicated that the pain was controlled with NSAIDs and an anti-convulsant drug used for neuropathic pain.  Physical examination showed a slow, cautious, abnormal, gait reflecting significant discomfort.  There was evidence of pes planus with no arch present when the patient stood.  There was no foot edema or instability of the ankles.  Ankle range-of-motion (ROM) was normal bilaterally with dorsiflexion of 20 degrees and plantar flexion of 45 degrees.  ROM was not limited by pain, fatigue, weakness or lack of endurance.  There were well-healed 1 cm scars in the medial arches at the base of the heels.  There was diffuse tenderness to palpation in the medial plantar fascia and over the heels.  The VA C&P examination listed the diagnoses of bilateral plantar fasciitis, bilateral equinus deformity and bilateral calcaneal spur documented by X-rays.

The Board first considered whether each the right and left foot condition were separately unfitting when considered alone.  Following initiation of the MEB process, the bilateral foot complaints were treated equally and concurrently.  Little distinction was documented between the bilateral feet by the CI or examiners.  Both feet were treated with surgical plantar fascial releases and the CI reported equal limitations preventing performance of prolonged walking, standing and running.  The Board majority concluded that the constellation of findings from the service medical records, radiographic reports and commander’s statement found the CI’s right and left foot conditions separately unfitting.

The Board directs attention to its rating recommendation based on the above evidence.  The PEB rated chronic bilateral plantar fasciitis and equinus deformity of feet 0% (coded 5399-5310; analogously to muscle Group X, foot muscles).  The VA rated the pes planus, equinus deformity, Achilles and plantar spur, status post plantar fascial release due to plantar fasciitis involving left foot 20% and right foot 20%, moderately severe (coded 5299-5284; analogously to foot injuries, other) based on the C&P examination.  The proximate examinations (MEB and C&P) documented chronic bilateral foot pain, exacerbated by prolonged weight bearing and activity.  The CI reported bilateral foot pain impacted her ability to exercise or participating in sports and recreation.  The C&P examination documented an abnormal gait, pes planus and tenderness to palpation of the plantar fascia.  There was no foot edema or instability of the ankles.  Bilateral ankle ROM was normal and not limited by pain, fatigue, weakness, or lack of endurance.  There is no specific diagnostic code for plantar fasciitis.  The VASRD diagnostic codes used by the PEB and the VA rate similarly based on an assessment of impairment as slight (0%), moderate (10%), moderately severe (20%) and severe (30%).  All Board members agreed the limitations described and examination findings did not exceed a moderate level and discussed whether the condition more nearly approximated the slight or moderate.  Members concluded the abnormal gait on the C&P examination favored the moderate over the slight impairment.  Members noted the VA rating for moderately severe, but agreed the condition did not more nearly approach this level than the moderate.  The Board also considered VA diagnostic code 5276 for acquired flatfoot.  All members agreed the condition did not exceed the moderate level (10%, unilateral or bilateral).  Under this code, mild (0%) indicates symptoms are relieved with orthotics.  The Board noted the CI’s symptoms were improved with orthotics but the impairment was better described by the moderate level under this code.  The 20% rating under 5276 would require severe unilateral disability with evidence of marked deformity, accentuated pain on manipulation and use, swelling on use, or characteristic callosities.  The Board then discussed whether a single 10% rating for the bilateral foot condition under 5276 was more appropriate than a 10% rating for each foot under 5284 (foot injuries other) or 5310 (muscle group 10).  The Board concluded the overall disability picture supported a separate 10% rating for each foot.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt) and §4.7 (higher of two ratings), the Board recommends a disability rating of 10% for the chronic plantar fasciitis and equinus deformity involving left foot condition and 10% for the chronic plantar fasciitis and equinus deformity involving right foot condition (VA code 5299-5284).

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.  In the matter of the chronic bilateral plantar fasciitis and equinus deformity condition, the Board, by a vote of 2:1, recommends separately unfitting disability ratings of 10% for the right foot and 10% for the left foot coded 5299-5284 IAW VASRD §4.71a.  The single voter for dissent did not elect to submit a minority opinion.  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 her prior medical separation:

UNFITTING CONDITION	VASRD CODE	RATING	
Chronic Left Plantar Fasciitis, and Equinus Deformity	5299-5284	10%	
Chronic Right Plantar Fasciitis, and Equinus Deformity	5299-5284	10%	
COMBINED (w/ BLF)	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20131009, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

		

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, AR20150002630 (PD201301817)

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:

CF: 
(  ) DoD PDBR
(  ) DVA