RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	 	CASE:  PD-2014-00087	
BRANCH OF SERVICE:  Army	 SEPARATION DATE:  20080206		 

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-3 (Ammunition Specialist) medically separated for a bilateral foot condition. The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS).  He was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  The bilateral foot condition, characterized as “bilateral plantar fasciitis,” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other conditions were submitted by the MEB.  The informal PEB adjudicated “plantar fasciitis, bilateral feet,” as unfitting, rated 0%.  The CI made no appeals and was medically separated.  

CI CONTENTION:  He was not evaluated for an asthma, PTSD or GERD/Barnett Esophagus conditions.  His complete submission is at Exhibit A. 

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 when specifically requested by the CI, those conditions identified by the PEB, but determined to be not unfitting.  Any conditions outside the Board’s defined scope of review and any contention not requested in this application may remain eligible for future consideration by the Board for Correction of Military/Naval Records.  Furthermore, the Board’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The Board’s assessment of the PEB rating determinations is confined to review of medical records and all available evidence for application of the Veteran’s Affairs Schedule for Rating Disabilities (VASRD) standards to the unfitting medical condition at the time of separation.  The Board has neither the role nor the authority to compensate for post-separation progression or complications of service-connected conditions.  That role and authority is granted by Congress to the Department of Veterans Affairs, operating under a different set of laws.  The Board gives consideration to VA evidence, particularly within 12 months of separation, but only to the extent that it reasonably reflects the severity of the disability at the time of separation. 

RATING COMPARISON:  
   
Service Admin IPEB – Dated 20080410	VA - (4 Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Plantar Fasciitis	5399-5310	0%	Bilateral Plantar Fasciitis	5299-5276	30%	20080625	
Other x 0 (In Scope)	Other x 17		
Combined:  0%	Combined:  30%	
*Derived from VA Rating Decision (VARD) dated 20080916 (most proximate to date of separation [DOS]).   

ANALYSIS SUMMARY:  

Bilateral Plantar Fasciitis Condition.  The earliest note in the service treatment record dated 25 September 2006 indicated the CI had significant pain of the left foot with walking or running for a month.  Examination revealed marked tenderness of the proximal third of the sole (heel or hind foot area) and the medial (inner) aspect of the foot.  The diagnosis of plantar fasciitis of the left foot was made and treatment consisted of Lodine (etodolac, a nonsteroidal anti-inflammatory drug (NSAID)).  An X-ray series of the left foot demonstrated minimal plantar spurring at the calcaneal (heel bone) attachment to plantar aponeurosis (thick connective tissue) was present.  In October 2006, the CI had pain on palpation of the medial plantar calcaneal tubercle and plantar fascia along with pes valgo planus (flatfoot due to an everted calcaneus) deformity bilaterally with a gastroc-soleus equinus (lack of ankle joint dorsiflexion due to congenital or acquired short gastro-soleus muscle complex).  Dorsiflexion was limited up to about 2 degrees with the knee extended and the knee flexed.  He also had a hallux abducto valgus deformity (bunion) bilaterally, which were asymptomatic.  Treatment consisted of a steroid injection and stretching exercises along with biomechanical rigid orthotics.  Taping helped, and as soon as it was removed, the pain returned necessitating reapplication.  Examination in June 2007 revealed excessive pronation (inward movement) of both feet with mild flat foot deformity bilaterally and tenderness on palpation of the calcaneal tuberosities of both feet and the mid and lateral midfoot.  In June 2007, physical therapy noted the CI had failed to improve in the prior year despite physical therapy before deployment, three steroid injections, stretching exercises and cold packs as well as custom orthotics.  The CI was returned to CONUS where examination revealed pes planus of both feet with planter tenderness bilaterally and a full range-of-motion.  X-rays in July 2007 confirmed the bilateral pes planus without any fracture or dislocation.  On 27 July 2007, a podiatrist discussed with the CI all treatment options for plantar fasciitis including conservative versus surgical; and, plantar fasciotomy (release of the fascia) was to be the last resort.  Despite conservative therapy, the CI’s symptoms persisted and he opted for an MEB.  Examination in August 2007 revealed bilateral pes planus with plantar tenderness and pain on motion, but was otherwise normal.  

At the MEB examination dated 6 August 2007, the CI reported on the DD Form 2807-1 that the plantar fasciitis originated in basic training in April 2006 and was treated with Flexeril (cyclobenzaprine, a muscle relaxant), Darvocet (propoxyphene, a narcotic and acetaminophen, a pain reliever, Mobic (meloxicam, an NSAID) and orthotics; however, the problem still persisted.  The MEB physical examination dated 8 August 2007 noted “pain both feet with ROM” and with asymptomatic and normal arch circled.  In contrast at the CI’s MEPS examination on 22 October 2005, he was noted to have asymptomatic mild pes planus.  The commander’s statement dated 15 August 2007 indicated the CI was physically incapable of reasonably performing critical field duties or his duties as an ammunition specialist due to his chronic feet problems for which he was returned from deployment.  

The MEB narrative summary (NARSUM) dated 27 September 2007 noted the CI stated he had constant pain while walking and climbing stairs.  Inserts did not provide any relief and he used his regular boots for stability when walking.  An examination performed by podiatry of both feet revealed tenderness of palpation of the anterior medial tubercle with decreased dorsiflexion with the knees straight and bent and no swelling of the plantar aspects.  Both arches were lower [than normal] and the left arch was somewhat lower than the right.  The CI’s gait showed no limping, but he walked from the lateral aspect of his foot inward and there were no eversion or inversion abnormalities.  The examiner’s diagnosis was bilateral plantar fasciitis.  A permanent L3 profile for bilateral plantar fasciitis was issued in October 2007 with limitations of no running, no marching, no rucking, no jumping, and no high impact activity as well as no moving with a fighting load and no rushes under fire.

At the VA Compensation and Pension (C&P) examination dated 25 June 2008, performed 4 months after separation, the CI reported pain, stiffness, and fatigability of the feet around the forefoot and heel of each foot precipitated by walking, standing, and climbing stairs.  He did not use any assistive aids for walking.  The weight bearing line was over or medial to the great toes and each foot demonstrated pronation.  X-rays of the both feet dated 12 June 2008 demonstrated moderate to severe pes planus bilaterally with a moderate size left sided plantar calcaneal spur and a right-sided plantar calcaneal tuberosity.  There were mild mid tarsal and calcaneocuboid faults (an increase in plantar joint space width where plantar surfaces do not align) with narrowing of the sinus tarsi bilaterally (between the ankle and hind foot).  Additionally, there were mild hallux valgus (bunion) deformities with mild lateral flexion of the distal phalanges (bones) of the hallucis (big toes) and mild osteoarthritis and flexion deformities of the interphalangeal joints from the second through the fifth toes.  The impression was pes planus (flat foot) with a left plantar calcaneal spur and a right calcaneal tuberosity.  On examination there was tenderness and rigidity of both feet.  Mild hallux valgus deformities and lateral flexion of the distal phalanges deformities were present with the weight bearing line over or medial to the great toes with mild pronation.  There was pain at rest and on manipulation.  Dorsiflexion was 20 degrees bilaterally and plantar flexion was 45 degrees bilaterally with no loss of motion on repetitive use.  The CI was seen by podiatry in August 2008, 6 months post-separation, with the complaint of sore, aching feet that existed for 2 years.  The pain was worse when he arose in the morning and progressed throughout the day and he was scheduled for surgery, which was performed on the left foot in June 2009. 

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 0% rating using code 5399-5310 (Group X. Function:  Movements of forefoot and toes-slight) for plantar fasciitis, bilateral feet.  The VA assigned a 30% rating using code 5299-5276 (Flatfoot acquired) for bilateral plantar fasciitis.  The Board sought a route to a higher rating aware that both the PEB and the VA used analogous codes, albeit different. 

Board Approach to PEB Consolidated Rating.  The PEB combined the left and right plantar fasciitis conditions under a single disability rating, coded analogously to 5310 presumably assigning a 0% rating to the left and right plantar fasciitis separately.  The Board’s initial charge in this case was directed at determining if the PEB’s combined adjudication was justified in lieu of separate ratings.  If justified separately unfitting by performance based criteria, then each condition is separately rated IAW VASRD §4.7 (higher of two evaluations) and separate ratings are recommended.  In this case, both the left plantar fasciitis and right plantar fasciitis under the rubric of bilateral plantar fasciitis were profiled, considered to fail retention standards, and implicated by the NARSUM and in the commander’s statement.  Members agreed that each foot plantar fasciitis is separately unfitting and that identical coding and ratings are applicable unless a bilateral rating applies.  

First the Board looked at options under code 5310.  The CI’s findings favored the etiology of the pain to be centered on the plantar aponeurosis and plantar ligament, which are in proximity to the X-ray confirmed calcaneal spur on the left and the calcaneal tuberosity on the right.  Because the CI did not achieve pain relief with conservative modalities including steroid injections, the Board considered a moderate disability at a 10% rating for each foot was not unreasonable.  While the VA assigned a 30% rating using analogous code 5276 for bilateral severe acquired flatfoot, the Board did not find objective evidence of a marked deformity of either foot, albeit the VA X-rays that indicated moderate to severe pes planus; however, while there was pain on use, there was no swelling or callosities in evidence and pronation at the time of the VA examination was mild, although it was “excessive” on examination in June 2007.  Nevertheless, the Board considered the 30% rating to be a possibility, but the Board did, however, find a moderate rating of 10% to be accurate, based on pain on manipulation and use of the feet.  However, a 10% rating is the maximum that can be assigned whether the disability is unilateral or bilateral.  In the absence of weakness of the feet or bilateral acquired claw foot, metatarsalgia, significant hallux valgus, hammer toes, malunion or nonunion of the tarsal or metatarsal bones, or foot injuries the Board was unable to find a route to a higher rating.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% for the left plantar fasciitis condition and a disability rating of 10% for the right plantar fasciitis 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.  As discussed above, PEB likely reliance on AR 635-40 and/or the VASRD for rating bilateral plantar fasciitis was operant in this case and the condition was adjudicated independently of that regulation by this Board.  In the matter of the left plantar fasciitis condition, the Board unanimously recommends a disability rating of 10%, coded 5399-5310 and in the matter of the right plantar fasciitis condition a disability rating of 10% coded 5399-5310, IAW VASRD §4.71a.  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 his prior medical separation:  

UNFITTING CONDITION	VASRD CODE	RATING	
Left Plantar Fasciitis	5399-5310	10%	
Right Plantar Fasciitis	5399-5310	10%	
COMBINED (w/ BLF)	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20131216, 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 XXXXXXXXXXXXXXXXXX, AR20160000319 (PD2014900087)

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