RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-01147
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20040807

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an National Guard E-5 (Combat Engineer) medically separated by the Informal Physical Evaluation Board (PEB) for “bilateral plantar fasciitis with underlying bilateral gastrocnemius equinus with foot dorsiflexion discogenic low back pain”; with a combined disability rating of 0%.

CI CONTENTION:  His conditions continue to get worse and impact his daily activities.  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 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 – 20040406	VA - 20051118	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Plantar Fasciitis… Bilateral Gastrocnemius Equinus with Foot Dorsiflexion	5399-5310	0%	Right Gastrocnemius Muscle Pain w/ Achilles Tendonitis	5099-5024	10%	20050920	
			Left Gastrocnemius Muscle Pain w/ Achilles Tendonitis 	5099-5024	10%	20050920	
			Plantar Fasciitis, Left Foot	5284	10%	20050920	
			Plantar Fasciitis, Right Foot	5284	10%	20050920	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:

Bilateral Plantar Fasciitis.  The CI first reported bilateral foot pain in April 2003 after moving heavy equipment and performing increased exercise in preparation for military activation.  Initially treated for tendonitis, he eventually was diagnosed with bilateral plantar fasciitis by podiatry in August 2003 noting tenderness to 1/3 of the left plantar fascia and 1/2 of the right plantar fascia.  The DD Form 2808 (Medical Board examination) dated 22 January 2004 revealed ‘severe and symptomatic pes cavus’ as being present with the diagnosis of bilateral plantar fasciitis.  Three months prior to separation (26 April 2004), the CI was again seen by podiatry who documented palpatory pain along both plantar fascia (right > left).  His physical findings included “equinus” whereby the feet do not dorsiflex beyond that of being perpendicular (right angle) to the leg.  A physical therapy report of 17 May 2004 noted pes cavus and assessed the CI’s condition as “severe (R>L) bilateral plantar fasciitis.”  Under the care of podiatry, the CI’s non-surgical conservative treatments did not relieve his painful symptoms and he was referred to the Medical Evaluation Board (MEB).

At the MEB narrative summary (NARSUM) examination (12 November 2003; 9 months pre-separation) the CI reported bilateral foot pain causing the inability to perform any weight-bearing activity.  The physical examination revealed tenderness along the plantar fascia and the dorsal aspect of both feet.  Additionally, the left foot was tender along the inside of the heel.  The right heel did not demonstrate tenderness.  Discriminatory sensation was intact to both feet and ankles and foot strength was assessed as normal.  “Ankle joint dorsiflexion was noted to be at 0 degrees bilaterally [expected in ‘equinus’] without pain or crepitus.”  There was no comment on ankle plantar flexion.  The diagnosis was bilateral plantar fasciitis and bilateral gastrocnemius equinus.  The examiner noted the CI’s condition as ‘stable’.  The commander’s statement clearly recommended that the CI be found unfit for duty due to his physical restrictions and inability to perform all the duties required by his military rating.

At the VA Compensation and Pension (C&P) examination (20 September 2005; 13 months post-separation) the CI reported a daily occurrence of bilateral plantar foot pain that extends into his ankles and metatarsals.  Aggravating factors include running and prolonged weight-bearing.  “There were no flare-ups of pain resulting in additional motion loss, fatigue, or incoordination of the gastrocnemius muscles.”  The physical exam noted mild tenderness to the plantar fascia, metatarsal heads, and the heel bilaterally.  Ankle range-of-motion (ROM) was measured at 10 degrees of dorsiflexion and 30 degrees of plantar flexion.  There was no evidence of ankle instability, calf tenderness, muscle spasms, or atrophy.  His VA diagnosis remained plantar fasciitis as well as chronic metatarsalgia and degenerative joint disease.  His pain was assessed as “stable.”

The Board directed attention to its rating recommendation based on the above evidence.  The Board first acknowledged and agreed that the pre-existing bilateral gastrocnemius equinus condition was permanently aggravated by military service.  The Board members agreed that the onset of increased physical activity as part of mobilization preparation, indeed was an aggravating factor of the CI’s bilateral plantar fasciitis condition.

The Board next determined the VASRD does not have a specific code for plantar fasciitis and it must be rated analogously.  The PEB and VA chose different coding options for the condition and both were IAW §4.73 and §4.71a, respectively.  The PEB chose to bundle the feet and assign an analogous muscle code 5399-5310 (Group X, movement of forefoot and toes) at 0% (slight).  The VA’s rating decision chose to separately rate and assign 10% each foot with VASRD code 5284 (Foot injury; other), citing permanent service aggravation of a pre-existing underlying deformity of ‘bilateral gastrocnemius equinus with foot dorsiflexion’ as well as bilateral Achilles tendonitis with an additional 10% rating each foot coded analogously under 5024 (Tenosynovitis) for a total combined rating of 40%.

The Board first deliberated over examination probative value and concluded that the DD Form 2808 of January 2004, the podiatry exam of April 2004, and the physical therapy exam of May 2004, be apportioned greater probative value over both the NARSUM and VA exams since they were more proximate the date of separation.
Members then considered whether each foot condition remained separately unfitting, having decoupled them from the combined PEB adjudication.  In consideration of separate ratings, the Board must also consider separate fitness assessments which justify each disability rating.  Although the right foot was noted to be the more symptomatic; the foot conditions were linked by common pathology and diagnosis, bilateral designations on all of the medical assessments, and jointly failed retention standards.  The members agreed, therefore, that attempting to separate out the left foot as not unfitting was overly speculative and arbitrary.  The Board agreed that equivalent coding was in order for separate service ratings, and deliberated appropriate coding options.  Members considered other separate analogous coding schemes and concluded that the 5310 muscle code was the best fit given the pathology present and being the more conventional choice for this condition.  Since the specific criteria of VASRD §4.56 for muscle injuries are not very practical for rating under this analogous use of the code, the Board relied on its judgment for more subjective assignment of the rated severity.  All members agreed that ‘moderately severe…20%’ or ‘severe…30%’ characterizations were not supported by the evidence.  Deliberations ensued as to rating the feet as ‘moderate…10%’ each, or rating right foot 10% and left foot at ‘slight…0%’.  At the conclusion of deliberations, considering the totality of the evidence and mindful of VASRD §4.3 (Reasonable doubt), the Board recommends a separate 10% rating for each foot condition.  The Board also considered bilateral foot rating options IAW VASRD §4.71a (Pes cavus and metatarsalgia), but none would rate more than the above recommendation.

BOARD FINDINGS:  In the matter of the bilateral foot condition, the Board unanimously recommends separate disability ratings of 10% each foot, coded 5310 IAW VASRD §4.73.  There were no other conditions within the Board’s scope of review for consideration.

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	
Plantar Fasciitis, Left Foot	5310	10%	
Plantar Fasciitis, Right Foot	5310	10%	
RATING	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20131027, 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, AR20160003625 (PD201401147)

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, accept the Board’s recommendation to modify the individual’s disability rating to 20% without re-characterization 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