RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXXX	 CASE:  PD-2014-00981	
BRANCH OF SERVICE:  Army	 BOARD DATE:  20151013
SEPARATION DATE: 20060420		 

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty Army E-4 (UH-60 Crew Chief) medically separated for neck and foot conditions.  The conditions could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS).  He was issued a permanent U3L3 profile and referred for a Medical Evaluation Board (MEB).  The neck and feet conditions, characterized as “cervical spondylosis,” “plantar fasciitis (PF) bilateral” and “tarsal tunnel syndrome (TTS) bilateral” were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also identified and forwarded “migraine headaches” as medically acceptable for PEB adjudication.  The informal PEB adjudicated “chronic neck pain secondary to degenerative disc disease (DDD)” and “long-standing bilateral PF with associated TTS “as unfitting, rated 10% and 0%, respectively with likely application of the US Army Physical Disability Agency (USAPDA) pain policy.  The remaining condition was determined to be not unfitting.  The CI made no appeals and was medically separated.

CI CONTENTION:  His conditions continue to worsen and negatively impact his daily activities.  Additionally, he was not evaluated for his PTSD condition by the PEB.  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 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 IPEB – Dated 20060224	VA - (6 Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Neck Pain 	5299-5242	10%	Cervical Spondylosis	5237	20%	20061030	
Bilateral Plantar Fasciitis with Associated Tarsal Tunnel Syndrome	5399-5310	0%	Bilateral Ankle Tarsal Tunnel Syndrome and Plantar Fasciitis	5299-5276	10%		
Other MEB/PEB Conditions x 1 (Not In Scope)	Other x 8 (Not in Scope)	
Combined/Rating:  10%	Combined:  50%	
Derived from VA Rating Decision (VARD) dated 20070118 (most proximate to date of separation [DOS]).   

ANALYSIS SUMMARY:  

Chronic Neck Pain Condition.  Absent direct trauma, the CI reported acute onset of neck pain in February 2005 after field exercise training.  Radiographic tests revealed multi-level DDD of the cervical spine.  The service treatment record (STR) noted extension of neck pain into his head, but denied typical and anatomic related extension into his arms.  In January 2006, he was permanently profiled with multiple diagnoses to include cervical spondylosis (degenerative changes) and referred to a MEB.  At the MEB examination (13 January 2006; 3 months prior to separation), the CI reported severe neck pain associated with tightness and stiffness.  The physical examination (PE) was brief and noted ‘no specific spinal tenderness’.  Neuro-sensory examination was normal.  Measured ROMs (obtained 5 weeks later [24 February 2006] revealed decreased and painful motion.  At the VA examination (30 October 2006; 6 months post-separation), the CI did not report any new or additional subjective issues pertaining to his neck condition.  The PE revealed decreased cervical ROM.  There was no comment in regards to the presence of painful motion or any degree of radiculopathy.  The diagnosis remained unchanged as cervical spondylosis.  The goniometric ROM evaluations in evidence which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below.

Cervical ROM
(Degrees)	PT ~ 2 Mo. Pre-Sep	VA C&P ~ 6 Mo. Post-Sep	
Flex (45 Normal)	(30) 30,30,30	30	
Extension (45)	(20) 20,20,20	30	
R Lat Flexion (45)	(10) 10,10,10	45	
L Lat Flexion (45)	(30) 30,30,30	45	
R Rotation (80)	(60) 60,60,60	60	
L Rotation (80)	(55) 55,50,55	60	
Combined (340)	205	270	
Comment	painful motion	-	
§4.71a Rating	10%-20%	20%	

The Board directed attention to its rating recommendation based on the above evidence.  Although the PEB and VA titled the unfitting neck condition slightly differently, they both utilized similar primary codes of 5242 (degenerative arthritis) and 5237 (cervical strain) and rated 10% and 20% respectively; citing pain by the PEB and additional limited motion by the VA.  Board members first considered examination probative value (PV) in this case between the above charted PT evaluation and the VA examination and agreed that despite the difference in timeframe from separation, both exams remained quite consistent with compensable flexion ROM measurements that support a 20% impairment rating.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 20% for the neck pain condition.

Bilateral Plantar Fasciitis with associated Tarsal Tunnel Syndrome Condition.  The CI was being treated for bilateral PF in late 2004.  A magnetic resonance image (MRI) note suggested evidence of bilateral PF and TTS for clinical correlation and assessment.  Periostitis was listed as an examination finding in both feet in November 2004.  Despite non-surgical treatments to include medications, local injections, and orthotics, his bilateral foot pain continued.  His profiled diagnosis was listed as chronic bilateral PF and TTS.  At the MEB examination (1 September 2005; 8 months prior to separation) the CI endorsed constant bilateral foot pain causing him the inability to carry out any duties except for sitting behind a desk.  “He cannot stand, or be on his feet for longer than 20 minutes without a significant increase in pain.”  “Wearing his combat boots helped with the TTS symptoms but made his PF pain worse.”  No physical abnormalities were noted under a general medical examination and ‘no relevant information’ was listed under a focused examination.  The DD Form 2808 was reported as normal.  The VA C&P examination (30 October 2006; 6 months post-separation) did not report specific information regarding PF, but rather provided subjective comments with regards to bilateral TTS.  The CI attributed that military lifestyle/activities have contributed to his condition.  The PE revealed tenderness about both heels.  There was normal ROM of both feet without comment IRT pain upon motion.  Strength and neuro-sensory testing of both feet were normal based upon various toe-heel gait analyses.  The final diagnosis was bilateral TTS, ‘substantiated by MRI’.  

The PEB chose to bundle the feet and assign an analogous muscle code 5399-5310 (Group X) at 0% (slight).  The VA’s original rating decision also chose to bundle and assign 10% with an analogous code of 5299-5276 (acquired flat feet), citing ‘palpatory pain’.  The Board first considered whether each foot condition remained separately unfitting, having decoupled them from the combined PEB adjudication.  Acknowledging a bilateral condition, Board members first considered the primary diagnosis in this case.  The action officer opined and members agreed that the MRI findings of periostitis was sufficient as to make a diagnostic determination of PF and that the clinical correlation for a primary diagnosis of TTS was minimal at best.  Therefore, the Board agreed with the PEB that any aspect of TTS was truly only ‘associated’ with the diagnosis of PF and not a second and separate primary condition.       

The clinical evidence within the STR overwhelmingly reflected that the left foot was associated with more symptomatology and impairment than the right.  The disparity was such that the question was raised of whether the right foot was reasonably justified as separately unfitting.  Although it remains speculative to conclude that the disability confined to the right foot would have rendered the CI incapable of performing within his MOS, Board member consensus was that it was reasonable to surmise that the combination of both painful feet was the condition which rendered him the permanent profiled restrictions and therefore, making him unfit for continued military service.  Board members further agreed that examination evidence of foot tenderness in the presence of periostitis is most accurately depicted by VASRD diagnostic code of 5020 (synovitis).  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a bundled disability rating of 10% for the painful feet 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 reliance on the USAPDA pain policy DoDI 1332.39 for rating the neck and feet was operant in this case and the conditions were adjudicated independently of that policy/instruction by the Board.  In the matter of the neck condition, the Board unanimously recommends a disability rating of 20%, coded 5299-5242 IAW VASRD §4.71a.  In the matter of the bilateral foot condition, the Board unanimously recommends a bundled disability rating of 10%, coded 5299-5242 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; and, that the discharge with severance pay be recharacterized to reflect permanent disability retirement, effective as of the date of his prior medical separation: 

UNFITTING CONDITION	VASRD CODE	RATING	
Chronic Neck Pain	5299-5242	20%	
Bilateral Plantar Fasciitis 	5020	10%	
COMBINED with b/l factor	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140211, 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 XXXXXXXXXXXXXXXXXXX, AR20150018237 (PD201400981)

1.  Under the authority of Title 10, United States Code, section 1554(a), I approve the enclosed recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) pertaining to the individual named in the subject line above to recharacterize the individual’s separation as a permanent disability retirement with the combined disability rating of 30% effective the date of the individual’s original medical separation for disability with severance pay.  

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:

	a.  Providing a correction to the individual’s separation document  showing that the individual was separated by reason of permanent disability retirement effective the date of the original medical separation for disability with severance pay.

	b.  Providing orders showing that the individual was retired with permanent disability effective the date of the original medical separation for disability with severance pay.

	c.  Adjusting pay and allowances accordingly.  Pay and allowance adjustment will account for recoupment of severance pay, and payment of permanent retired pay at 30% effective the date of the original medical separation for disability with severance pay.

	d.  Affording the individual the opportunity to elect Survivor Benefit Plan (SBP) and medical TRICARE retiree options.

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:

			      
						      					
Enclosure
					
CF: 
(  ) DoD PDBR
(  ) DVA