RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-01846
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20050907

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E4, Petroleum Supply Specialist, medically separated for “bilateral foot pain” with a disability rating of 10%.

CI CONTENTION:  The CI indicates he was rated 10% each for his left ankle, right ankle, left foot, and right foot.  He also contends he should have been separated for (and received a rating due to) asthma.  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 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 - 20050606	VARD - 20051102	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Foot Pain…	5399-5310	0%	Bilateral Plantar Fasciitis	5310-5020	20%	20050729	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Bilateral Foot Pain.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s bilateral foot condition began in July 2003 while deployed.  The CI’s military enlistment physical noted the CI had bilateral, mild pes planus (flatfoot) that was asymptomatic.  A podiatry evaluation on 11 March 2004 showed good pulses and sensation of both feet.  There was a flexible pes planus bilaterally with tenderness to palpation (TTP) of the left heel, but not the right.  There was full ROM of the ankles and subtalar joints, without pain or crepitus.  The diagnosis was flexible pes planus and plantar fasciitis bilaterally.  Weight bearing X-rays of the feet in May 2004 and bilateral ankle X-rays in November 2004 were normal.  Subsequent podiatry visits noted bilateral plantar fasciitis and equinus deformities (limited ankle dorsiflexion) and variable Achilles tendonitis (left) and anterior tibial tendinitis (right greater than left).  Despite extensive conservative treatment the bilateral foot condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and the CI was referred for an MEB.  The MEB forwarded “chronic plantar fasciitis” and “equinus deformity of the bilateral ankles” for PEB adjudication.

The permanent profile listed “chronic bilateral foot pain” with physical limitations of no running, jumping, or marching and “no LBV, flack vest, or rucksack.”  According to the commander’s statement, bilateral PLANTAR FASCIITIS impaired the CI’s performance of his duties and participation in physical fitness training.

The MEB examination (recorded on DD Forms 2807 and 2808) dated 18 November2004, 10 months prior to separation, noted bilateral foot pain, left greater than right, with TTP of both feet.  At the MEB NARSUM examination on 23 February 2005, 6 months before separation, the CI reported pain in both feet first thing in the morning, aggravated by prolonged weight bearing activities.  The physical examination showed TTP of the bottom of both feet along the plantar fasciitis and TTP of the tibialis anterior tendons (active in foot DF) bilaterally.  There was normal ROM of the feet and toes without pain.  Bilateral ankle ROM was 10 degrees DF with the knee flexed and 0 degrees with the knee extended (normal 20 degrees).   There was no swelling, or discoloration of the feet or ankles.  Circulation and sensation in the LEs was normal.  The MEB NARSUM examiner indicated the CI failed retention standards due to physical limitations due to bilateral foot pain, which might improve when the CI was no longer in the military environment.

At the VA Compensation and Pension (C&P) examination on 29 July 2005, 1 month before separation, the CI reported daily foot pain with swelling, aggravated by WB activities and no treatment had improved his pain to any significant degree.  Physical examination showed a normal gait with normal foot architecture, but partial flatfoot with weight bearing.  There was normal alignment of the Achilles tendon.  There was no evidence of abnormal weight bearing.  There was no swelling of either foot and no TTP of the bottom of the heel of either foot.  There was tenderness of the foot with manipulation.  Ankle ROM was normal, without painful motion or swelling.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB combined the bilateral foot conditions as a single condition and rated 0%, coded as 5399-5310 (as noted above), analogous to “slight” muscle injury.  The original VA Rating Decision also rated the plantar fasciitis conditions 0%, coded 5310-5020 (muscle group X injury – synovitis) as a single bilateral condition.  (Both 5399-5310 and 5099-5020 are analogous codes for plantar fasciitis).  The VA cited plantar fasciitis without evidence of limitation of motion of a major joint or a minor joint (as specified according to 5003 rating criteria which apply to 5020).  

Directing attention to its recommendations, the Board first considered if the both the left and right foot conditions met the Board’s threshold for separate rating (as elaborated above).  Both foot conditions were permanently profiled and the listed physical limitations were equally applicable to both feet.  The commander’s statement implicated bilateral plantar fasciitis as impairing the CI’s duty performance.  The NARSUM noted the physical limitations attributable to both feet caused the CI to fall below retention standards and indicated that equivalent treatment had been provided for both feet.  The Board concluded that there was not a preponderance of evidence in record that overcame the Board’s presumption that each foot condition is reasonably considered separately unfitting.  The Board then considered its rating recommendations for the unfitting right foot and unfitting left foot conditions together at the time of separation.

The Board reviewed the rating criteria of 5399-5310 which are subjective, with a 0% rating for “slight”, 10% rating for “moderate”, 20% for “moderately severe,” and 30% for “severe” muscle injury.  The Board considered that when coding the disability due to plantar fasciitis analogously as 5310 IAW VASRD §4.73, the discrimination between the “slight” and “moderate” characterizations depends on the presence of at least one “cardinal sign or symptom” of muscle injury specified as “loss of power, weakness, lowered threshold of fatigue, fatigue-pain, impairment of coordination and uncertainty of movement” for “moderate”, as opposed to none for “slight.”  In the STR and at the MEB examination the CI reported constant bilateral foot pain aggravated by WB activities.  Therefore, the Board concluded that based on the presence of pain with use and tenderness with manipulation of each foot, the disability due to both foot conditions was best described as “moderate” and not “slight” and each foot met the 10% rating, but judged it could not be characterized as “moderately severe” for either foot, which by analogy Members judged would require greater objective evidence of foot abnormalities such as deformity, swelling, or callosities.  Alternatively coding the foot conditions IAW VASRD §4.71a a 10% rating for each foot could be supported coded as 5099-5020 for painful motion with functional loss (based on §4.59, §4.40 and §4.45) or with 5284 (other foot injury) for “moderate” foot injury, but by similar reasoning as noted for the 5310 criteria the Board did not find the evidence supports characterizing either foot injury as “moderately severe” for higher individual ratings.  The podiatrist diagnosed the CI with equinus deformity (limited ankle/foot DF) which can be congenital or acquired.  The ankle ROM was noted to be moderately limited at the MEB examination but normal and without discomfort at the C&P examination and ankle X-rays were normal.  Therefore, consideration of coding the foot disabilities with a VASRD ankle code was abandoned.  Coding the bilateral pes planus condition as (acquired flatfoot) 5276 provides no ratings benefit because it provides a 10% rating for “moderate” pes planus with pain on manipulation of the feet whether unilateral or bilateral and there was no evidence of “severe” pes planus (marked deformity with swelling and characteristic callosities), or claw foot or malunion or nonunion of tarsal or metatarsal bones of either foot.  There was therefore no higher rating than 10% with any applicable VASRD code for either foot.  The Board recommends a 10% rating for each foot, coded 5399-5310.

BOARD FINDINGS:  In the matter of the bilateral foot condition, the Board unanimously recommends that each foot be separately adjudicated as follows: an unfitting right foot condition and an unfitting left foot condition, each rated 10%, and both coded 5399-5310 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 the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Right Foot Pain	5399-5310	10%	
Left Foot Pain	5399-5310	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140429, 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 XXXXXXXXXXXXXXXXXXXXX AR20160010653 (PD201401846)

1. I have reviewed the enclosed Department of Defense Physical Disability Board of
Review (000 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
( ) OVA