RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02530
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20050205

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Signal Support Systems Specialist, medically separated for “chronic bilateral ankle pain…due to chronic talo-fibular ligament tear,” and “[bilateral] severe pes planus and plantar fasciitis,” rated 0% and existed prior to service (EPTS) and not permanently aggravated by such service, respectively, with a combined disability rating of 0%.  

CI CONTENTION:  “Consider all conditions found unfitting and not unfitting by the physical evaluation board.”  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 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 - 20041124	VARD - 20050713	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Bilateral Ankle Pain	5099-5003	0%	Left Ankle Stress Reactive Degenerative Changes	5010-5271	10%	STR	
			Right Anterior Talofibular Ligament Tear…	5010-5271	10%	STR	
[Bilateral] Severe Pes Planus & Plantar Fasciitis	5299-5276	EPTS	Left Pes Planus with Plantar Fasciitis	5276-5284	10%	STR	
			Right Pes Planus with Plantar Fasciitis	5276-5284	10%	STR	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Bilateral Ankle Pain.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s bilateral ankle pain began in early 2003 after performing physical fitness training.  Serial X-rays revealed enlargement and swelling of foot bones adjacent to her ankles as well as ligamentous degenerative changes about the right ankle.  Despite non-surgical conservative treatment, her symptomatic condition did not improve.  The MEB forwarded “bilateral ankle pain”, as well as two additional diagnoses for PEB adjudication.  At the MEB orthopedic examination dated 14 April 2004, 10 months prior to separation, the CI reported persistent bilateral ankle pain with running, marching, and prolonged standing.  Her physical examination (PE) revealed near normal bilateral ankle range of motion (ROM) with surrounding tenderness.  Although the record noted, “right ankle larger than left”, there was no evidence of ankle edema, ecchymosis, effusion, or instability.  Neuromuscular motor activity was normal.  There was no comment with regards to painful motion.  Her diagnosis remained as “bilateral ankle pain” and her clinical and functional status was listed as “stable”.  Throughout the STR there were various encounters that indicated inconsistent findings of one ankle being more symptomatic that the other.  The case file did not contain a full VA Compensation and Pension (C&P) examination but rather a ‘screening’ examination one month after separation.  As a screening examination, it does not capture the detailed information about a specific condition that is necessary for rating purposes.  Therefore, the Board placed higher probative value on clinical encounter evidence near the time of separation as well as the MEB NARSUM in the determination of a final impairment rating. 

The Board directed attention to its rating recommendation based on the above evidence.  The PEB bundled the bilateral ankle condition and analogously coded it as 5099-5003 (degenerative arthritis) at 0%; whereas, the VA separately rated each ankle at 10% under the dual code of 5010-5271 (traumatic arthritis-ankle limited motion).  The Board first considered if each ankle, having been de-coupled from the combined PEB adjudication, remained separately unfitting and ratable.  In consideration of separate ratings, the Board must also consider separate fitness assessments which justify each disability rating.  The Board acknowledged that the sole remarkable PE finding of bilateral ankle tenderness without comment with regards to painful motion did not warrant application of VASRD §4.59 for a minimum of 10% as applied unilaterally or bilaterally.  There was evidence which was equivocal, and often inconsistent in severity for each ankle.  Although it is speculative to conclude that the disability confined to the either ankle would have rendered the CI incapable of performing within her occupational rating, Board member consensus was that it was also reasonable to surmise that it was the overall effect of both ankles which rendered her unfit.  The Board concluded that the bilateral diagnosis did support a single analogous 5003 rating for “2 or more major joints,” as conferred by the PEB.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a single disability rating of 10% for the bilateral ankle condition.

Bilateral Pes Planus & Plantar Fasciitis.  The Board’s main charge regarding these conditions was an assessment of fairness of the PEB’s existed prior to service (EPTS) determination.  The Board’s authority for recommending a change in the service’s EPTS determination is not specified in DoDI 6040.44, but is considered adjunct to its DoD-specified obligation to review fitness adjudications.  

The STR did not reveal any direct evidence of a clinical diagnosis of plantar fasciitis (PF), but rather the symptomatic and diagnostic emphasis remained as bilateral pes planus.  However, all Board members agreed that despite the absence of any objective PF diagnosis, its close relatedness in the presence of severe pes planus is well correlated in medical literature.  In this case, the issue of EPTS was inconsistently documented between the MEB and PEB with the MEB noting no condition as EPTS and the PEB citing PF and pes planus as EPTS without permanent service aggravation (PSA) under analogous VASRD code of 5299-5276 (flatfoot).  Utilizing the STR, the VA dual coded each foot as 5276-5284 (flatfoot-foot injury; other) and rated each foot 10%, citing ‘benefit of the doubt in the [CI’s] favor subsequent to lost medical records and the absence of an induction PE from the case file.  Therefore, PSA was presumed since the CI was released from Service in part due to PF symptoms’ in the presence of pes planus.  The MEB indicated the presence of pes planus as a diagnosis, but did not reveal objective evidence of foot abnormalities outside that of tenderness across the top of both feet as well as the middle 1/3 of the bottom. 

The Board directed attention to its rating recommendation based on the above evidence.  Absent the CI’s induction PE, all Board members agreed that they could not state with certainty if the CI entered the service with normal foot arches or not.  Additionally, Board members could not ascertain as to the PEB’s reasoning and determination that the presumed EPTS condition was not PSA when the increase in service-related physical activities caused the CI’s symptomatic pain in both feet.  After extensive deliberation, all members agreed that the required demands of military service did permanently aggravate the CI’s prior existence of pes planus and that a combination of both feet appropriately supported an aggravated impairment condition.  In consideration of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% analogously coded 5299-5276 (flat foot, acquired, moderate).  Evidence of record did not support the severe level of disability under this coding option.  The Board noted the 5276 rating code was most appropriate given the CI’s diagnosis and clinical evidence.  Furthermore, VASRD code 5276 for flatfoot, acquired at the moderate level, conveys a rating of 10% for either unilateral or bilateral conditions.

BOARD FINDINGS:  In the matter of the bilateral ankle condition the Board unanimously recommends a single disability rating of 10% coded 5003 IAW VASRD §4.71a.  In the matter of the bilateral pes planus and PF conditions the Board unanimously recommends a single 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 the prior to medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Bilateral Ankle Pain	5099-5003	10%	
Bilateral Pes Planus and Plantar Fasciitis 	5299-5276	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140531, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MEMORANDUM FOR Commander

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for XXXXXXXXXXXXXXXXXX, AR20160013615 (PD201402530)

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 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
(  ) DVA