RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXX	CASE:  PD-2014-02250
BRANCH OF SERVICE:  Army	BOARD DATE:  20140715
SEPARATION DATE:  20020601

SUMMARY OF CASE:  The available evidence of record reflects that this covered individual (CI) was an active duty PFC/E-3 (92Y10/Unit Supply Specialist) medically separated for bilateral plantar fasciitis.  The condition could not be adequately rehabilitated to meet the requirements of her Military Occupational Specialty or physical fitness standards, so she was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  Plantar fasciitis bilateral, bilateral knee retropatellar pain syndrome and left iliotibial band were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The Informal PEB adjudicated bilateral planter fasciitis as unfitting, rated 0%, with likely application of the VA Schedule for Rating Disabilities (VASRD).  The remaining conditions were determined to be not unfitting.  The CI made no appeals and was medically separated.

CI CONTENTION:  “PLEASE CONSIDER ALL CONDITIONS”

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44, Enclosure 3, paragraph 5.e.(2).  It is limited to those conditions determined by the PEB to be unfitting for continued military service and those conditions identified but not determined to be unfitting by the PEB when specifically requested by the CI.  The ratings for the unfitting feet condition and not unfitting bilateral knee and Iliotibial band conditions, as per the contention, are addressed below.  Any condition or contention not requested in this application, or otherwise outside the Board’s defined scope of review, remain eligible for future consideration by the Board for Correction of Military Records.

IAW DoDI 6040.44, the Board’s authority is limited to making recommendations on correcting disability determinations.  The Board’s role is thus confined to the review of medical records and all evidence at hand to assess the fairness of PEB rating determinations, compared to VASRD standards, based on ratable severity at the time of separation.

RATING COMPARISON:

Service IPEB – Dated 20020404	VA* - (1 Mo. Pre-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Plantar Fasciitis Bilateral	5399-5310	0%	Residuals Right Foot Endoscopic Plantar Fascial Release	5299-5020	10%	20020502	
			Residuals Left Foot Endoscopic Plantar Fascial Release	5299-5020	10%	20020502	
Bilateral Knee Retropatellar Pain Syndrome	Not Unfitting	Retropatellar Pain Syndrome Right Knee	5299-5014	10%	20020502	
		Retropatellar Pain Syndrome Left Knee	5299-5014	10%	20020502	
Left Iliotibial Band Fraction	Not Unfitting	Iliotibial Band Syndrome Left Hip	5255-5019	0%	20020502	
Other x 0 (Not in Scope)	Other x 0	
Combined:  0%	Combined:  40%	
* Derived from VA Rating Decision (VARD) dated 20020517 (most proximate to the date of separation (DOS))

ANALYSIS SUMMARY:  The Board noted that the CI was diagnosed with multiple sclerosis (MS) in March 2008, with subsequent bilateral leg weakness and neurologic symptoms.  However, this diagnosis was approximately 6 years after separation and there was no indication in the service treatment record of specific symptoms or diagnosable components of MS proximate to separation.  The Board therefore focused on the fitness and ratings of the MEB/PEB conditions at the time of separation.

Plantar Fasciitis Bilateral Condition.  The narrative summary (NARSUM) noted bilateral foot pain beginning in basic training that did not resolve with inserts (orthotics).  Bone scan documented left foot stress fracture and right foot stress reactions and diagnoses progressed to bilateral plantar fasciitis and symptoms were not relieved by changes in orthotics or injections.  Prolonged rest (>30 days) appeared to significantly reduce the symptoms, but bilateral foot pain returned with resumption of activities.  The CI underwent surgery on both feet (endoscopic plantar fascia release in October [right] and December [left] 2001) with initial relief of only left foot pain.  Continued right foot pain and left foot pain which returned interfered with duty performance.  Pain was aggravated by increased walking, standing and running.  The L3 profile listed “Plantar fasciitis bilaterally (foot pain).”

At the MEB exam, the CI reported painful bilateral heels, left greater than right.  The MEB physical exam noted pain on palpation of both feet (at the plantar medial aspect of the calcaneus extending into the arch).  Neurologic, vascular, strength, reflexes and ankle range-of-motion (ROM) testing were normal.  The DD Form 2808 physical documented pes planus with painful plantar palpation.

At the VA Compensation and Pension (C&P) exam performed a month prior to separation, the CI reported daily foot pain with minimal weight bearing with comfortable walking limited to 20 feet.  Orthotics and transcutaneous electrical nerve stimulation (TENS) use did not provide relief and she was limited to wearing tennis shoes or comfortable flat shoes.  Exam documented evidence of bilateral plantar fascia releases with tender scars and marked tenderness to palpation over the plantar fascia bilaterally.

The Board directs attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral foot condition as 5399-5310, analogous to Group X muscle injury at slight (0%).  The VA rated the condition as 5299-5020, analogous to synovitis for each foot, with application of painful motion for a 10% rating of each foot.  The PEB combined the left foot and right foot conditions under a single service disability rating.  The Board, IAW VASRD §4.7 (higher of two evaluations), must consider separate ratings for PEB bilateral joint adjudications; although, separate fitness assessments must justify each service disability rating.  In this case, both feet were considered to fail retention standards; both had surgery and both were implicated by the NARSUM were profiled.  Members agreed therefore that each foot condition should be reasonably conceded as separately unfitting; and, that coding and rating features were logically identical.  The Board noted that the service and VA exams were similar and deliberated on coding/rating each foot condition.

Plantar fasciitis is not specifically listed in the VA rating schedule and the Board considered VASRD §4.20 (analogous ratings) for rating “under a closely related disease or injury in which not only the functions affected, but the anatomical localization and symptomatology are closely analogous.”  There was no actual muscle injury IAW VASRD §4.73, (schedule of ratings–muscle injuries) with the specific rating considerations of §4.55 and §4.56.  The Board adjudged that the VA applied coding of 5299-5020, analogous to synovitis under §4.71a (schedule of ratings–musculoskeletal system) at 10% for each foot, best aligned with the CI’s disability condition at the time of separation.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends that each foot be separately unfitting with a disability rating of 10% for the left foot plantar fasciitis, and 10% for the right foot plantar fasciitis condition.

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that bilateral knee retropatellar pain syndrome and left iliotibial band fraction were not unfitting.  The Board’s threshold for countering fitness determinations is higher than the VASRD §4.3 (reasonable doubt) standard used for its rating recommendations, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.

Bilateral Knee Retropatellar Pain Syndrome Condition.  The orthopedic consult for the NARSUM, performed 4 months prior to separation, indicated worsening of bilateral knee pain for 7-8 months with difficulty with prolonged walking (>10 min) and pain when going up/down stairs and increased pain when standing from a seated position.  She was not taking medications, but was on a “very limited profile” for her feet and “she states that she is unable to run due to her knees as well.”  Prior bone scan in October 2001 (proximate to basic training) noted bilateral shin splints and possible right thigh splint.  Examination of her bilateral knees demonstrated tenderness to palpation over the anterior and lateral kneecap with some mild joint line tenderness.  She had a positive patellar grind test.  There was no evidence of laxity, instability, motor or sensory deficits or muscle atrophy.  Plain X-rays of the knees were reported as normal.  The DD Form 2808 physical documented bilateral patellar crepitation and the DD Form 2807-1 (medical history) indicated report of “right knee pops and swells” after activity.

At the VA C&P exam performed a month prior to separation, the CI reported onset of knee pain during Advanced Individual Training with significant worsening after her foot surgeries.  There was no specific knee trauma and no history of swelling or locking.  “Walking is limited primarily due to the plantar fasciitis.”  Examination documented tenderness over the patella.  There was no crepitus, effusion, or instability and ROM was normal.  The diagnosis was bilateral retropatellar pain syndrome.  The VA rated this exam at 10% for each knee.  The VA exam in August 2005, over three years post separation indicated symptom worsening and left foot surgery in May 2005.

The Board directs attention to its rating recommendation based on the above evidence.  The bilateral knee retropatellar pain syndrome was profiled and was judged to fail retention standards.  There was a temporal linkage to worsening of knee symptoms with the bilateral foot surgery.  The primary aspect of the CI’s duty limitations were restrictions based on her lower extremities and inability to run, jump, or walk/march which were attributed to her unfitting bilateral plantar fasciitis condition.  The record indicates that the CI was originally referred for MEB due to her plantar fasciitis and that the knee complaints and record entries followed after MEB referral.  There was no documentation of significant medications, seeking treatment, surgeries, or other than conservative treatment with non-steroidal anti-inflammatory medications.  There was insufficient performance based evidence from the record that the knee conditions significantly interfered with satisfactory duty performance.  After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the contended knee conditions and so no additional disability ratings are recommended.

Left Iliotibial Band Fraction Condition:  The left iliotibial band fraction condition (snapping hip syndrome) was not profiled and was not judged to fail retention standards.  The orthopedic consult dated 6 February 2006 indicated the CI had noticed snapping in her left hip that she could cause voluntarily.  Exam indicated audible and palpable snapping over the left hip.  There was symmetric ROM of her bilateral hips with no evidence of grinding or intra-articular pathology on exam.  Although the L3 profile from the feet and knees conditions may have overshadowed limitations caused by the left hip, there was insufficient anatomic or performance based evidence from the record that the left hip condition significantly interfered with satisfactory duty performance.  After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the contended left hip condition.

BOARD FINDINGS:  IAW DoDI 6040.44, provisions of DoD or Military Department regulations or guidelines relied upon by the PEB will not be considered by the Board to the extent they were inconsistent with the VASRD in effect at the time of the adjudication.  The Board did not surmise from the record or PEB ruling in this case that any prerogatives outside the VASRD were exercised.  In the matter of the bilateral plantar fasciitis condition, the Board unanimously recommends a disability rating of 10% for each foot separately, coded 5299-5020 IAW VASRD §4.71a.  In the matter of the contended bilateral knee retropatellar pain syndrome, the Board unanimously agrees that it cannot recommend it for additional disability rating.  In the matter of the contended left iliotibial band fraction condition, the Board unanimously agrees that it cannot recommend it for additional disability rating.  There were no other conditions within the Board’s scope of review for consideration.

RECOMMENDATION:  The Board recommends that the CI’s prior determination be modified as follows, effective as of the date of her prior medical separation:

UNFITTING CONDITION		VASRD CODE	RATING	
Plantar Fasciitis Bilateral	Left	5299-5020	10%	
	Right	5299-5020	10%	
COMBINED (w/ BLF)	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140520, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

		
XXXXXXXXXXXXXXXXX
President
Physical Disability Board of Review

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 XXXXXXXXXXXXXXXXX, AR20150006387 (PD201402250)

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,   I accept the Board’s recommendation to modify the individual’s disability rating to 20% without recharacterization 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:

Encl						     XXXXXXXXXXXXXXXXX
						     Deputy Assistant Secretary of the Army
						         (Review Boards)

CF: 
(  ) DoD PDBR
(  ) DVA