RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-01320
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20091227

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E2, Chaplain Assistant, medically separated for ““pes planus right foot with comorbid plantar fasciitis” and pes planus left foot with comorbid plantar fasciitis” rated 10% and 10%, respectively, with a combined disability rating of 20%.

CI CONTENTION:  The CI contends the continuing problems she experiences and contends for depression, anxiety, feet, headaches and her sleep problems.  The CI’s 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 based on 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 - 20091015	VARD - 20101214	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Pes Planus Right Foot with Comorbid Plantar Fasciitis	5276	10%	Right Foot Plantar Fasciitis with Pes Planus	5020-5276	10%	20090806	
Pes Planus Left Foot with Comorbid Plantar Fasciitis	5276	10%	Left Foot Plantar Fasciitis with Pes Planus	5020-5276	10%	20090806	
Tendonitis, Right Foot	Not Unfitting	Tendonitis, Right Ankle (Claimed as R/Foot and Torn Ligament)	5271	20%	20090806	
Major Depression	Not Unfitting	Depression with Amenorrhea and Insomnia	9434	50%	20090506	
Dysthmia disorder…	Not Unfitting					
Sleep Maintenance Insomnia	Not Unfitting					
Migraine Headaches	Not Unfitting	Migraine Headaches	8100	0%	20090512	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  70%	

ANALYSIS SUMMARY:  

Pes Planus Right Foot with Comorbid Plantar Fasciitis.  The service treatment records (STRs) and the MEB narrative summary (NARSUM) dated 22 September 2009 indicated the CI complained of bilateral foot pain and bilateral plantar fasciitis.  Moderate pes planus was noted to be asymptomatic and was not considered disqualifying on a MEPS examination dated 12 October 2004 prior to enlistment.  She was given orthotics, but was unable to perform her duties.  Magnetic resonance imaging (MRI) of the right foot in January 2009 showed plantar fasciitis, a partially torn anterior talofibular ligament, a fluid collection adjacent to the dorsal aspect of the talonavicular joint,  and mild tendinopathy of the Achilles tendon (see below).  At a podiatry visit in February 2009 the CI was noted to have severe bilateral pes planus.  She had been under the care of a civilian podiatrist and was pending surgical removal of the ganglion cyst of the foot in March 2009.  

A permanent L3 profile was issued on 17 April 2009 for severe congenital/symptomatic bilateral pes planus with limitations of all physical fitness testing, moving with a fighting load at least 2 miles and doing rushes under direct and indirect fire.  At the MEB examination dated 17 April 2009 the CI reported right foot pain more than the left and a cyst of the right foot and she could not stand without support.  X-rays of the right foot in May 2009 were negative.  A note in June 2009 indicated the CI wore an Aircast boot.  On examination there was a 1-1.5 cm rubbery nodule with minimal tenderness with palpation on the anterior aspect of the ankle over the extensor tendon and there was tenderness to palpation on the plantar surface of the right arch and around to right ankle where the nodule was located.  She was advised that surgery to remove the ganglion should be done after separation at the VA.  In the interim she was to continue to wear the boot for 7 hours a day and to decrease usage until the symptoms resolved.  

In September 2009, the NARSUM examiner noted the CI had been in a right foot boot, which was removed.  On examination she had normal posture and a normal gait.  There were no signs of abnormal weight bearing or breakdown, callosities or any unusual shoe wear pattern.  She did not use an assistive device for ambulation.  Right dorsiflexion was 16 degrees and right plantar flexion was 18 degrees; pain was present at the end of both motions.  With repetition dorsiflexion was 14 degrees with an additional degree of limitation of 2 degrees and plantar flexion was 18 degrees with no additional limitation.  On the right joint function was additionally limited after repetitive use due to pain, lack of endurance and the pain has the major functional impact.  Examination of the feet and toes revealed bilateral flat feet and plantar tenderness.  There was no painful motion, edema, disturbed circulation, weakness, atrophy of the musculature, heat, redness or instability of the right foot; however, there was active motion in the metatarsophalangeal (MTP) joint of the right great toe.  Pes planus was present as was a moderate degree of valgus, which could not be corrected by manipulation.  Additionally, the right foot showed forefoot-midfoot malalignment of a moderate degree, which also could not be corrected by manipulation, and there was a deformity of marked pronation.

At the VA Compensation and Pension (C&P) examination dated 6 August 2009, performed 4 months before separation, the CI reported the condition occurred while running and not having support. The pain was described as burning, sharp and cramping. Examination of the feet revealed bilateral flat feet and planter tenderness.  Palpation of the plantar surface of the right foot revealed slight tenderness.  Weight bearing and alignment of the Achilles tendon was normal on the right; a moderate degree of valgus was present; forefoot/midfoot malalignment was present as was a marked pronation deformity.  Pes cavus was not present. She neither had a bunion nor hammer toes and did not require any type of support with her shoes.

Pes Planus Left Foot with Comorbid Plantar Fasciitis. The service treatment records and the MEB narrative summary (NARSUM) dated 22 September 2009 indicated the CI complained of bilateral foot pain and bilateral plantar fasciitis.  X-rays of the left foot in May 2009 were negative and were again negative in July 2009.  At the NARSUM examination left dorsiflexion was 20 degrees and left plantar flexion was 45 degrees; pain was present at the end of both motions.  There was no additional loss of motion on repetition, but pain was present.  Examination of the feet and toes revealed bilateral flat feet and plantar tenderness. Examination of the left foot revealed tenderness, but there was no painful motion, edema, disturbed circulation, weakness, atrophy of the musculature, heat, redness or instability.  There was active motion in the MTP joint of the left great toe.  Pes planus was present and on the left there was a moderate degree of valgus present, which could not be corrected by manipulation. The left foot showed forefoot/midfoot malalignment of a moderate degree, which could be corrected by manipulation. On the left there was deformity of marked pronation. Pes cavus was not present. No hammertoes were present and no hallux valgus (bunion) was present.  She had “limitation with standing and walking,” but did not require any type of support with her shoes.  A permanent L3 profile was issued on 17 April 2009 for severe congenital/symptomatic bilateral pes planus with limitations of all physical fitness testing, moving with a fighting load at least two miles and doing rushes under direct and indirect fire.  At the MEB examination dated 17 April 2009 the CI reported foot pain more than the left and she could not stand without support.  

At the VA Compensation and Pension (C&P) examination dated 6 August 2009, performed 4 months before separation, the CI reported pain in the bottom of both feet.  The CI’s gait was within normal limits.  Examination of the feet did not reveal any signs of abnormal weight bearing or breakdown, callosities or any unusual shoe wear pattern.  She did not require any assistive device for ambulation.  The ROM measurements were 20 degrees for dorsiflexion and 45 degrees for plantar flexion.  There was loss of function on repetition due to pain.  Examination of the feet revealed bilateral flat feet and planter tenderness; and, examination of the left foot did not reveal painful motion, edema, disturbed circulation, weakness, atrophy of the musculature, heat, redness or instability. There was active motion in the MTP joint of the left great toe.  Palpation of the plantar surface of the left foot revealed slight tenderness and on the left there was a moderate degree of valgus present, which could not be corrected by manipulation. The left foot showed forefoot/midfoot malalignment of a moderate degree, which could not be corrected by manipulation and there was a deformity of marked pronation.  Pes cavus was not present, and neither hammer toes nor a hallux valgus was present. 

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating using code 5276 (flatfoot, acquired) for pes planus right foot with comorbid plantar fasciitis and a 10% rating using code 5276 for pes planus left foot with comorbid plantar fasciitis.  The VA assigned a 10% rating using code 5276 for left foot plantar fasciitis with pes planus and a 10% rating using code 5276 for right foot plantar fasciitis with pes planus.  Board members noted the CI had moderate pes planus on entrance to the service, albeit asymptomatic.  The Board sought a route to a higher rating at 30% using code 5276 (severe) and acknowledged there was objective evidence of a bilateral marked deformity (pronation), but there was no “pain on manipulation and use accentuated, indication of swelling on use, characteristic callosities.”  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 for pes planus right foot with comorbid plantar fasciitis and for pes planus left foot with comorbid plantar fasciitis conditions.  

Contended PEB Conditions:  Tendonitis, Right Foot.  The Board’s main charge is to assess the fairness of the PEB’s determination that the contended condition was not unfitting.  As noted above the CI had bilateral foot pain and bilateral plantar fasciitis.  She was given orthotics, but was unable to do her MOS.  Magnetic resonance imaging (MRI) of the right foot in January 2009 showed plantar fasciitis, a partially torn anterior talofibular ligament, fluid collection adjacent to the dorsal aspect of the talonavicular joint, and mild tendinopathy of the Achilles tendon. She wore an Aircast boot on the right foot, the use of which was tapered to 7 hours and it was removed for the NARSUM examination.  The CI had been under the care of a civilian podiatrist and was pending surgical removal of the ganglion cyst of the foot in March 2009, which was recommended to be deferred until post-separation.  At the VA examination the CI reported pain in the bottom of both feet and right ankle; right lower leg pain occurred constantly and was described as burning, sharp and cramping with a pain level of 8/10, which was exacerbated by physical activity and relieved by ibuprofen (a nonsteroidal anti-inflammatory drug (NSAID)).  The CI’s gait was normal.  Alignment of the Achilles tendon was normal on the right for both weight bearing and non-weight bearing.  

The 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.

Ankle ROM
(Degrees)	MEB/NARSUM ~4 Mo. Pre-Sep	VA C&P ~8 Mo. Pre-Sep	
	Left	Right	Left	Right	
Dorsiflexion (20 Normal)	20	16(14)*	20	16(14)*	
Plantar Flexion (45)	45	18	45	18	
Comment	Pain at the end of motion	Pain at the end of motion	Pain on repetition	Pain on repetition	
§4.71a Rating	PEB 10% (pes planus with plantar fasciitis)	PEB 10% (pes planus with plantar fasciitis)	10% VA (plantar fasciitis with pes planus)	10% VA (plantar fasciitis with pes planus)	
                                     *Additional loss of motion on repetition

Board members first discussed whether the tendonitis of the right foot, which actually involved the ankle as well and was defined and rated as for an ankle disability by the VA, was separately and independently unfitting and agreed it was based on a preponderance of evidence supported by the facts that the CI wore a boot on her right foot for an extended period, which limited her capability of performing her duties as well as supporting MRI findings and limitation of motion of her ankle, which further impaired her from performing full duty.  The Board directed attention to its rating recommendation based on the above evidence.  Board members discussed code 5284 (foot injuries, other) at a 10% rating; however, since the right foot also had an unfitting condition, pes planus right foot with comorbid plantar fasciitis, the possibility of pyramiding IAW VASRD §4.14, which is to be avoided, was raised, but Board members noted that the foot condition and the ankle not only have separate functions as well as combined functions, but also have separate VASRD ratings thereby avoiding pyramiding.  Therefore, as a result of the torn talofibular ligament, encompassing the foot and the ankle, the right ankle had limited motion and on the VA examination there was pain on repetition.  Code 5271 (ankle, limited motion-moderate) justifies a 10% rating for the right ankle (dorsiflexion 80% of normal and plantar flexion 40% of normal) and is supported by a MRI findings of a partially torn anterior talofibular ligament, a possible ganglion cyst and mild tendinopathy of the Achilles tendon.  The Board members discussed whether the condition rose to a marked limitation of the foot/ankle with a 20% rating.  After due deliberation, the Board agreed that the preponderance of the evidence with regard to the functional impairment of tendonitis of the right foot favors its recommendation as an additionally unfitting condition for disability rating.  It is appropriately coded 5284-5271 and meets the VASRD §4.71a criteria for a 10% rating. 

Other Contended PEB Conditions: Major Depression, Dysthymia, Sleep Maintenance/Insomnia, and Migraine Headaches.  The Board’s main charge is to assess the fairness of the PEB’s determination that the contended conditions were not unfitting.  None of the conditions were profiled or implicated in the commander’s statement or judged to fail retention standards.  There was no performance-based evidence from the record that any of the conditions significantly interfered with satisfactory duty performance at separation.  After due deliberation, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for any of the contended conditions and so no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the pes planus right foot with comorbid plantar fasciitis condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the pes planus left foot with comorbid plantar fasciitis condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended tendonitis, right foot/ankle condition, the Board unanimously agrees that it was unfitting and unanimously recommends a disability rating of 10%, coded 5284-5271 IAW VASRD §4.71a.  In the matter of the contended major depression, dysthymia, sleep maintenance/insomnia, and migraine headaches conditions, the Board unanimously recommends no change from the PEB determinations as not unfitting.  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; and, that the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective as of the date of her prior medical separation:  

CONDITION	VASRD CODE	RATING	
Pes Planus Right Foot with Comorbid Plantar Fasciitis	             5276	10%	
Pes Planus Left Foot with Comorbid Plantar Fasciitis	5276	10%	
Tendonitis, Right Foot	5284-5271	10%	
RATING (w/ BLF)	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140304, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

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 AR20160013303 (PD201401320)

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 re-characterize 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