RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX		CASE:  PD-2014-00258
BRANCH OF SERVICE:  Army		SEPARATION DATE:  20060614

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a Guard E4, Multichannel Transmission Systems Operator, medically for “chronic low back pain” and “bilateral plantar fasciitis, rated 10% and 0%, respectively, with a combined disability rating of 10%.

CI CONTENTION:  He was not evaluated for PTSD.  His complete submission is at Exhibit A.

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44.  It is limited to those conditions determined by the Physical Evaluation Board (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 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 Veterans 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 PEB - 20060518	VARD – 20070118	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain 	5237	10%	Low Back Strain	5237	10%	20060922	
Bilateral Plantar Fasciitis	5399-5310	0%	Right Foot Hallux Valgus…	5276-5280	10%	20060922	
			Left Foot Hallux Valgus…	5276-5280	10%	20060922	
Personality Disorder	Not Unfitting	PTSD w/ Adjustment Disorder	9411	50%	20061003	
COMBINED RATING:  10%	COMBINED RATING FOR ALL VA CONDITIONS:  80%	

ANALYSIS SUMMARY:

Chronic Low Back Pain without Motor Neurologic Abnormality.  The record shows a history of low back pain (LBP) first evaluated in 1993.  In 2004, he had recurrent LBP which was treated with medications and physical therapy.  On 20 November 2004, he was noted to have good strength and full range-of-motion (ROM).  On 11 May 2005, X-rays were normal.  The CI was reevaluated in physical therapy rehabilitation on 6 July 2005.  He was noted to have significant tightness in both the hamstrings and the piriformis (a muscle in the buttocks).  His ROM was reduced and he was begun on stretching exercises.  Magnetic resonance imaging (MRI) on 5 October 2005 showed a disc bulge L4-5 and L5-S1, but no nerve impingement.  His ROM showed significant improvement at the 12 August 2005 physical therapy evaluation as charted below.  Formal ROM testing in physical therapy on 24 October 2005 was reduced as charted below.  The examiner noted that the CI had recent bunion surgery.  The Board noted that the decrease in ROM is not inconsistent with decreased flexibility associated with post-operative limitations in activity after the surgery.  At the medical Evaluation Board (MEB) examination on 28 October 2005, 8 months prior to separation, the ROM was noted to be limited by pain, but the neurological examination was normal.  The narrative summary (NARSUM) was dated 1 November 2005.  He reported LBP since April 2004 associated with lifting and endorsed numbness going down his right leg to his toes.  He had a normal gait and stance.  Heel walk was normal, but he could not toe walk due to recent surgery on his bunions.  The ROM referenced the physical therapy measurements obtained on 24 October 2005 and is charted below.  Tenderness of the paraspinal muscles was present, but spasm was not recorded.  A nerve conduction velocity study was normal (indicating absence of a radiculopathy).

At the VA Compensation and Pension (C&P) examination performed on 22 September 2006, 3 months after separation, the CI reported that he could not lift over 10 pounds, walk over 1/4 mile, stand longer than 10 minutes, or sit over an hour.  He reported four episodes of incapacitation the past year.  Each lasted 7 days for a total of 28 days.  On examination, his gait and posture were normal.  Pain radiated to the right leg.  His ROM was limited by pain and repetition resulted in an additional 5 degrees of limitation.  A sensory deficit was noted in the L4 and L5 distribution bilaterally.  The sciatic nerve was the most likely peripheral nerve involved.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB and VA both rated the back at 10%, coded 5237 (lumbosacral strain).  The VA C&P examination was most proximate to separation and accomplished with a goniometer.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the chronic LBP condition.  The Board also considered if an unfitting radiculopathy was present at separation.  Motor function was intact.  Sensation was recorded as both normal and showing a deficit at different examinations.  Electrodiagnostic testing was normal though.  Regardless, there was no evidence that a neurological deficit impaired duty.  Accordingly, an unfitting radiculopathy was not found to be present at separation.  The Board concluded therefore that this condition could not be recommended for additional disability rating.

Bilateral Plantar Fasciitis.  The CI was first seen for right foot pain on 22 December 2004 while deployed. He reported an injury during physical fitness training in June of that year.  He was thought to not meet retention standards and an MEB was recommended.  He was then referred to podiatry for right > left bunions (hallux valgus).  Podiatry recommended surgery and medical evacuation to his home station for treatment.  X-rays showed bilateral bunions, but were otherwise unremarkable (no fracture and no flat feet).  Surgery on the right foot was accomplished on 18 March 2005.  His recovery was uneventful.  On 18 May 2005, he was issued orthotics for plantar fasciitis.  He subsequently underwent surgical repair of the left bunion and again recovered uneventfully.  The NARSUM on 7 October 2005 noted that the CI was profiled to wear a shoe of comfort.  The CI reported persistent pain after the surgeries as well as from the plantar fasciitis.  On examination, as noted above, he had a normal gait and stance, but toe walk was not possible secondary to pain.  The plantar fascia was tender bilaterally as were the post-surgical scars.

At the VA Compensation and Pension (C&P) exam performed 3 months after separation, the CI reported pain with walking, running, and jumping.  On examination, his gait and posture were normal.  He used orthotics.  Manipulation of the feet was painful, but malalignment was not present.  Pes planus was present clinically.  The Board noted that this was not diagnosed by the podiatrist nor was it present on multiple X-rays.  The examiner commented that the “symptoms and pain are relieved by the previously described corrective shoe wear” (orthotics).  X-rays of both feet including weight bearing views were normal other than changes from the bilateral bunionectomies.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated unfitting bilateral plantar fasciitis at 0%, coded 5399-5310 (Group X muscle impairment: forefoot and toes).  The VA rated the bilateral foot conditions at 10% each, coded 5276-5280 (pes planus-hallux valgus), described as right/left foot hallux valgus, plantar fasciitis and pes planus (flat feet), status post bunionectomy.  The Board considered the findings.  The initial MEB dated 13 January 2006 included bilateral foot pain, after bilateral bunionectomies, and bilateral plantar fasciitis as failing retention standards.  The second MEB, which was 3 months later and more remote from surgery, forwarded only the bilateral plantar fasciitis as failing retention standards, implying that the post-operative pain now met retention standards.  Neither MEB forwarded pes planus.  As neither the pes planus condition nor the post-operative pain from bilateral bunionectomies was considered by the PEB or the final MEB, these are outside the Scope of the Board.  The VASRD does not have a specific code for plantar fasciitis.  However, the code 5310 does encompass the plantar fascia (plantar aponeurosis).  While the CI did have tenderness on examination, he was noted to have a normal gait and that his symptoms were resolved with the use of orthotics.  This supports a finding of a slight impairment, but does not support a moderate impairment.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the bilateral plantar fasciitis condition.  The Board did note that each foot could be considered separately unfitting, but this provides no rating advantage to the CI.

Contended PEB Conditions.  The CI specifically contended for PTSD [posttraumatic stress disorder].  While this condition was determined to fail retention standards by the initial MEB, the second, and final, MEB forwarded a personality disorder which was noted to be medically acceptable.  The final profile noted the personality disorder and was S1.  No restrictions from a mental health condition were listed.  The commander’s comments were non-specific.  The PEB determined that it was not unfitting.  The Board’s threshold for countering fitness determinations requires a preponderance of evidence, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.  It was reviewed and considered by the Board.  There was no performance based evidence from the record that it significantly interfered with satisfactory duty performance.  After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the personality disorder condition and so no additional disability rating is recommended.  The Board did note that PTSD was initially determined to fail retention standards and was rated by the VA.  

BOARD FINDINGS:  In the matter of the low back pain and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the bilateral plantar fasciitis condition and IAW VASRD 4.73, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the implied contended personality disorder condition, the Board unanimously recommends no change from the PEB determination as not unfitting.  In the matter of the contended PTSD condition, it is outside the Scope of the Board.  There were no other conditions within the Board’s scope of review for consideration.  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 20140102, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs 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, AR20160005828 (PD201400258)

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:

Enclosure

CF: 
(  ) DoD PDBR
(  ) DVA