RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX		CASE:  PD-2014-01998
BRANCH OF SERVICE:  Army		SEPARATION DATE:  20031209

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4, Radio Operator/Maintainer, medically separated for “left plantar fasciitis” with a disability rating of 10%.

CI CONTENTION:  “Please consider all conditions”.  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 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 upon a 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 - 20031006	VARD - 20060606	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Plantar Fasciitis	5399-5310	10%	Left Foot Plantar Fasciitis	5399-5310	0%	20060215	
COMBINED RATING:  10%	COMBINED RATING FOR ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:

Left Foot Condition.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI injured his left lower extremity on a 20K road march when he stepped into a hole.  The CI presented to the emergency department on the day of injury and a diagnostic imaging (X-ray) showed a possible small avulsion (forcible separation/detachment) fracture at the base of the distal phalanx of the 2nd toe.  A diagnostic imaging (bone scan) study showed stress/mild avulsion related changes of the left hindfoot with no indication of stress fracture or fracture.  At a podiatry encounter, the CI complained of continued left foot pain with first steps when getting out of bed.  The assessment listed left plantar fasciitis (sole connective tissue inflammation) and posterior tibial tendonitis (acute tendon inflammation or irritation).  At a 3-month podiatry follow-up, the CI reported the left foot plantar fasciitis was 85-90% improved.  He had received the custom orthotics, no longer used crutches, and used a cane.  The physical examination revealed less tenderness of the left foot along the plantar fascia with no erythema (redness) or edema (excess tissue fluid swelling).  The assessment listed left plantar fasciitis and the plan was to continue with the custom orthotics and to transition off the cane.  At a 6-month podiatry follow-up, the CI complained of 8/10 pain in the balls of his feet and heels.  Pain was exacerbated with running and walking and he experienced no relief with nonsurgical care.  The physical examination revealed continued tenderness of the medial plantar fascia (left greater than right) and posterior tibial tendons with no erythema or edema.  Compression of the tarsal tunnel (canal formed between ankle bone [medial malleolus] and ligaments across foot [flexor retinaculum]) caused shooting pain to the medial left foot.  The assessment listed left plantar fasciitis and possible medial plantar nerve entrapment.  The podiatrist discussed treatment options (surgery vs. medical board) and recommended conservative management as surgery might not improve, and could worsen the condition.  He advised the CI that this condition would usually decrease once out of the military.

During the MEB NARSUM, 4 months before separation, the CI complained of foot pain but he “decided not to take pain medication and just put up with the pain because narcotics make him dizzy and he does not seem to get much relief from Ibuprofen.”  The CI did not experience significant improvement with conservative management (activity modification, crutches, splints, casting, custom boots, physical therapy, steroid injections, and medication) and surgery was not recommended.  The physical examination documented the CI walked with a limp, had difficulty toe and heel walking, and used a cane in his right hand.  The left foot examination revealed tenderness of the plantar surface and under the proximal 2nd metatarsal head.  The foot arch was present not weight bearing and standing.  Ankle range of motion (ROM) was dorsiflexion of 10 degrees (normal 20) and plantarflexion of 30 (normal 45).  The diagnosis listed left plantar fasciitis.

In the VA Compensation and Pension (C&P) examination, 26 months after separation, the CI complained of daily pain in the arch of the foot.  Pain was exacerbated by weight bearing, walking barefoot, walking (>45 minutes), running, jumping, and ambulation and was not relieved by orthotics or ice.  Painful flare-ups occurred twice per week and lasted for 4 to 5 hours.  The physical examination documented the CI walked with a limp and used a cane.  There was no evidence of lower extremity atrophy.  There was no pain on ROM and ROM was not additionally limited by pain, fatigue, weakness, or lack of endurance following repetitive use.  The left foot exam revealed a midline Achilles’ tendon with no callus, edema, arch tenderness, or pain on manipulation.  Strength, pulses, and deep tendon reflexes were normal.  The left foot X-ray was normal.  The diagnosis listed left plantar fasciitis.

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB rated the left foot condition 10%, analogously coded 5310 (muscle group X, foot muscles) citing moderate left plantar fasciitis, unresponsive to conservative treatment, problems with heel/toe walking, and use of a cane.  The VA rated the left foot condition 0% also analogously coded 5310 based on the VA C&P examination 26 months after separation, citing left foot plantar fasciitis with no evidence of muscle disability.

The Board agreed the examinations most proximate to separation documented an antalgic gait, motor function, deep tendon reflexes, and ROM which were normal.  There was no weakness for consideration under code 5277 (weak foot).  There was no evidence of sensory pathology for consideration under code 5279 (metatarsalgia).  There was no deformity for consideration under code 5276 (flatfoot), 5278 (claw foot), 5280 (hallux valgus), 5281 (hallux rigidus), 5282 (hammer toe), or 5283 (metatarsal bones malunion/nonunion).  The Board agreed that the foot symptoms more closely approximated the moderate (10%) than the moderately severe (20%) rating under code 5310 (muscle group X, foot muscles) or 5284 (foot injuries, other).  Board members also agreed that there was sufficient evidence of pain with use prior to separation, as well objective examinations and imaging findings, to support a 10% rating considering VASRD §4.40 (functional loss) and §4.59 (painful motion).  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 left foot condition.

BOARD FINDINGS:  In the matter of the left plantar fasciitis condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  There were no other conditions within the Board’s scope of review for consideration.  The Board, therefore, recommends that there be no re-characterization of the CI’s disability and separation determination.

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140505, 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 AR20160013531 (PD201401998)

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, I accept the Board’s recommendation and hereby deny the individual’s application.  
This decision is final.  The individual concerned, counsel (if any), and any Members of Congress who have shown interest in this application have been notified of this decision by mail.

 BY ORDER OF THE SECRETARY OF THE ARMY:

Enclosure

CF: 
(  ) DoD PDBR
(  ) DVA