RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-01544
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20070531

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E4, Military Police, medically separated for “bilateral foot pain,” with a disability rating of 0%.

CI CONTENTION:  The CI indicated her foot conditions are ongoing and have contributed to the deterioration of her back.  Her 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 - 20070307	VARD - 20070706	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Foot Pain	5399-5310	0%	Bilateral Plantar Fasciitis and Pes Planus	5299-5276	10%	20070419	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Bilateral Foot Pain (Plantar Fasciitis and Pes Planus).  The service treatment record (STR) and Medical Evaluation Board (MEB) narrative summary (NARSUM) documented initial care for bilateral foot pain in August 2005 (4 months after entry) with radiographs that documented a left foot stress fracture (first metatarsal bone).  Radiographic healing of the left foot was seen by September 2005, with resolution of the fracture by July 2006 (10 months pre-separation).  Radiographic imaging in November 2005 (19 months pre-separation) documented bilateral flattening of the plantar arches consistent with pes planus.  Radiographic imaging in January 2006 (17 months pre-separation) documented a bony defect in the base of the right great toe (first metatarsophalangeal joint) with radiographic resolution by July 2006.  
At a physical therapy visit in August 2006 (9 months pre-separation), the CI reported constant pain that was worse in the morning, during walking, running, and lifting heavy objects.  The examiner documented a normal gait, and full range-of-motion of the bilateral ankles.  There was tenderness of the heel, plantar fascia, and midfoot bilaterally, without swelling.  There was bilateral arch pain with full squat.  At a podiatry visit in November 2006 (6 months pre-separation), the CI reported bilateral foot pain with standing, walking, and exercise.  The examiner documented tenderness of the bilateral heels, instep [arches], and plantar feet, with normal foot and ankle motion and no evidence of painful motion.  At an orthopedic consultation in November 2006, the examiner documented bilateral pes planus with “fallen arches,” tenderness of the bilateral arches and plantar surfaces; and left heel pain.  There was no pain with motion of the bilateral foot, no evidence of right heel pain, and a normal gait.  On the MEB DD Form 2807-1, Report of Medical History, dated 13 December 2006 (5 months pre-separation), the CI reported use of orthotics.  On the MEB DD Form 2808, Report of Medical Examination, dated 13 December 2006 (5 months pre-separation), the examiner documented “arches starting to fall” and tenderness with all movements.  The final diagnosis was “mild symptomatic” pes planus.  

The MEB NARSUM examination was performed on 16 February 2007 (3 months pre-separation).  The CI reported constant bilateral foot pain with prolonged standing, and any running.  The pain also increased with walking and jumping and did not improve with custom orthotics.  The examiner documented bilateral pes planus with “fallen arches.”  Foot motion and gait were normal and did not elicit pain.  Tenderness was noted on palpation of the instep, and plantar surface of both feet and the transverse arch of the left foot.  Heel pain was present on the left and not on the right.  The motor examination was normal.  At a physical therapy visit in February 2007 (2 weeks later), the examiner documented pain limited range-of-motion (ROM); right dorsiflexion of 10 degrees (normal 20) and left dorsiflexion of 5 degrees; with normal plantar flexion bilaterally.  A normal heel to toe gait was documented.  

At the VA Compensation and Pension (C&P) examination performed on 19 April 2007 (1 month pre-separation), the examiner documented an “adequate” walk with “minimal” physical limitation and without assistive devices.  There was pain on palpation of the bilateral plantar surfaces and proximal feet.  There was heel pain with complete flexion, and pain with inversion and eversion.  There was no laxity of the ankles.  Ankle motion was normal with pain and stiffness noted.  Motor and sensory exams were normal.  

The Board directed attention to the rating recommendation based on the above evidence.  The PEB rated the bilateral foot condition 0% citing chronic pain, and analogously coded as 5399-5310 (muscle group X function) as it includes structures pertaining to the plantar aponeurosis.  The VA rated the bilateral foot condition at 10% and coded 5299-5276 (flatfoot, acquired) citing pes planus, painful motion, and arch supports that do not relieve the foot pain.  

The Board, IAW VASRD §4.7 (higher of two evaluations), must consider separate ratings for PEB bilateral joint adjudications; although, each joint must be reasonably justified as unfitting for separate disability ratings.  In this case, a bilateral condition was determined to fail retention standards, was profiled, and was implicated by the NARSUM and commander’s statement.  Each foot was documented to have had stress fractures and resultant pain consistent with pes planus and bilateral plantar fasciitis.  Members agreed that the evidence of the record reasonably supported that each foot condition was separately unfitting.  

The Board considered several coding avenues to include pathology extending along the entire foot and ankle.  The Board noted that there was no disorder of the muscles of the feet present (as applied by the PEB); however, the 5310 code includes “other important plantar structures: plantar aponeurosis, long plantar ligament, etc.…” and therefore, the use of this code is reasonable when applied unilaterally.  In this case, there was no documentation of abnormal foot movement or propulsion that would justify a “moderate” rating for either foot.  Unilateral foot coding (5284) was also considered; however there were no other abnormalities documented that would substantiate a “moderate” level of impairment for a rating under that code.  There was no weakness or atrophy in evidence to support code 5277.  There was no documentation of significant or chronic ROM deficits for rating under the 5270 and 5271 ankle codes.  There was documentation of healed bilateral stress fractures allowing consideration for coding under 5283, however, no evidence of malunion or nonunion was documented.  The 5276 code allows for rating of a unilateral or bilateral condition, based on the severity of clinical findings.  There was no objective evidence of marked deformity, swelling on use, or characteristic callosities, that would justify a “severe” rating for either foot.  There was documentation of “fallen arches,” intermittent pain on manipulation and use, and symptoms unrelieved by arch support that more clearly described the CI’s bilateral foot condition.  This description more nearly approximated a “moderate” rating and did support a single 10% rating (applied bilaterally in this case given each foot was separately unfit) for the bilateral feet analogously coded 5299-5276 (flatfoot, acquired).  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 bilateral foot condition.

BOARD FINDINGS:  In the matter of the bilateral plantar fasciitis and pes planus condition, the Board unanimously recommends a disability rating of 10%, coded 5299-5276 IAW VASRD §4.71a.  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 her prior medical separation:  

CONDITION	VASRD CODE	RATING	
Bilateral Plantar Fasciitis and Pes Planus 	5299-5276	10%	
RATING	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140301, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAMR-RB

28 JUL 2016

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, AR20160006752 (PD201401544)

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 10%
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