RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXX	CASE:  PD-2014-02674
BRANCH OF SERVICE:  NAVY 	SEPARATION DATE:  20061028

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-5, Master-at-Arms medically separated for bilateral plantar fasciitis.  The condition could not be adequately rehabilitated to meet the physical requirements of his Rating or satisfy physical fitness standards and he was referred for a Medical Evaluation Board (MEB).  The “bilateral pes planovalgus,” “plantar fascial strain/stress,” and “plantar fasciitis bilaterally” were forwarded to the Physical Evaluation Board (PEB) IAW SECNAVINST 1850.4E.  No other condition was submitted by the MEB.  The Informal PEB adjudicated “plantar fasciitis bilaterally” as unfitting, rated 10%, with application of the Veterans Affairs Schedule for Rating Disabilities (VASRD). The remaining condition were determined to be Category II (contributing to unfit). 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 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/Naval 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 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:  

IPEB – Dated 20060713	VA* - based on Service Treatment Records (STR) 	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Plantar Fasciitis Bilaterally	5399-5310	10%	Bilateral Pes Planus with Plantar Fasciitis	5276	0%	STR	
Pes Planovalgus Deformity	Cat II					
		Bilateral Foot Condition	5276	-	STR	
Other x 0 (Not In Scope)	Other x 5	
RATING:  10%	RATING:  0%	
*Derived from VA Rating Decision (VARD) dated 20070620 (most proximate to date of separation (DOS)).  

ANALYSIS SUMMARY:  

Plantar Fasciitis.  The service treatment record has very limited primary source material.  The earliest note dated 14 February 2006 indicated the CI complained of bilateral plantar foot pain for a couple of years that had become worse in the recent past.  The pain occurred when he worked out doing squats and after running.  He denied any known trauma to the feet. Examination revealed bilateral flat feet and was otherwise essentially unremarkable.  The diagnosis of congenital foot deformity-pes planus (flat foot) was made and the CI was referred to the podiatry clinic. On 30 March 2006, the CI stated his arches continued to hurt after wearing AliMed inserts and he stopped using them.  However, he noted standing with his feet inverted made him feel better.  Examination by a podiatrist revealed a pes planovalgus (physiologic flat foot) deformity bilaterally and tenderness of the arches bilaterally, but no tenderness of the heels.  X-rays to rule out inferior calcaneal (heel bone) spurs or midfoot degenerative joint disease revealed absence of the plantar arch and no bony or significant hallux valgus (bunion) deformity.  The findings (decreased calcaneal (heel bone) inclination angle bilaterally and naviculo-cuneiform (bones of the midfoot) sagging bilaterally) were further interpreted by the podiatrist to demonstrate flat feet.  Arch supports were replaced on 31 March 2006.  The CI presented to the Emergency Room on 1 April 2006 to request pain medication and noted his feet were becoming harder to walk on and were very painful with a severity of 6-7/10 (10 being the worst pain).  

The MEB narrative summary (NARSUM) dated 19 June 2006 noted the CI was first seen at the Podiatry Clinic on 13 April 2006 with pes planovalgus deformity, which existed prior to enlistment and plantar fasciitis bilaterally.  The CI underwent physical therapy, activity modification and a trial of nonsteroidal anti-inflammatory drugs without significant relief.  He additionally had a further trial of orthoses (orthopedic devices to support or align foot deformities) and cast immobilization.  He complained of heel pain radiating to the arches of both feet, unchanged from the time of onset and also complained of bilateral foot pain after periods of prolonged standing.  On physical examination the CI walked with an antalgic gait.  He was moderately tender in the inferior aspect of the heels (soles of the feet) bilaterally and there was evidence of pes planovalgus deformity.  The range-of-motion (ROM) measurements of the ankles were dorsiflexion 10 degrees (Normal 20 degrees) bilaterally and plantar flexion 20 degrees (Normal 45 degrees) bilaterally, while the subtalar joint ROMs were eversion 10 degrees (AAOS (American Academy of Orthopedic Surgeons) Normal 15 degrees) and inversion 20 degrees (AAOS Normal 35 degrees) bilaterally.  Neurological examination revealed no motor or sensory deficit.  X-rays of the feet were consistent with pes planovalgus deformity and the absence of a lateral arch; and there were no other bony abnormalities.  As a result of the plantar fasciitis bilaterally, he was unable to stand for 15 minutes, run, or lift greater than 30 pounds because of pain in his feet.  

The CI noted on the DD Form 2807-1, Report of Medical History, dated 4 May 2006, foot trouble and pain involving the plantar [areas] and flat feet.  The examiner noted on the DD Form 2808, Report of Medical Examination, symptomatic pes planus of the feet.  There was neither Limited Duty (LIMDU) documentation nor a non-medical assessment (NMA) in the STR.  Furthermore, no VA Compensation and Pension (C&P) examination was performed since the CI failed to report for the examination.

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB combined the plantar fasciitis bilaterally conditions under a single disability rating, coded analogously to 5399-5310 (Group X plantar muscles/aponeurosis) for the plantar fasciitis bilaterally.  Pes planovalgus deformity was determined to be a related Category II condition contributing to the unfitting condition.  Although VASRD §4.71a permits combined ratings of two or more joints, it also allows separate ratings for separately compensable joints.  IAW DoDI 6040.44 if the PEB combined adjudication is not compliant with the combined rating criteria, each condition subsumed under the single disability rating must be reasonably justified as separately unfitting in order to remain eligible for rating.  The Board’s initial charge in this case was directed at determining whether the PEB’s combined adjudication was justified in lieu of separate ratings.  The evidence for the conditions was presented jointly based on STR notes and the NARSUM.  If Board members determine by performance based fitness criteria that the condition is reasonably justified as separately unfitting and is separately ratable IAW VASRD §4.7 (higher of two evaluations), separate ratings are recommended.  IAW DoDI 6040.44 the combined rating for the conditions determined to be separately unfitting and ratable may not be lower than the single disability rating from the PEB.  The Board first considered whether plantar fasciitis of each foot could be reasonably justified as separately unfitting.  Members agreed that the evidence in the NARSUM supports the functional limitations of plantar fasciitis of each foot is separately unfitting and a separate rating is recommended as long as not precluded by the VASRD.  The Board then sought a route to a higher rating aware that the PEB rated both feet together with a 10% rating using analogous 5310 code IAW VASRD §4.73—Schedule of ratings–muscle injuries, by “bundling” the overall rating for bilateral plantar fasciitis.  However, the PEB should have applied separate ratings of 10% IAW VASRD §4.56 for each foot since the 5310 plantar muscle code (Group X) is commonly used for plantar fasciitis and is applied unilaterally.  The VA assigned a 0% rating using code 5276 (Flatfoot, acquired) for bilateral pes planus with plantar fasciitis and also used code 5276 for the bilateral foot condition, which it determined was not service-connected.  However, the VA’s use of code 5276 (Flatfoot, acquired) for bilateral pes planus with plantar fasciitis is problematic since there was no VA examination on which to base its coding.  The CI did have a pes planovalgus deformity diagnosis, presumably prior to enlistment, but the CI served more than 8 years on active duty thereby making the absence of MEPS evidence moot.  More importantly, the unfitting condition, plantar fasciitis, can be coded analogously 5299-5276 thereby capturing both the flatfoot and plantar fasciitis conditions.  However, neither foot was “pronounced” with marked pronation or “severe” in the absence of objective evidence of marked deformity, swelling on use, or characteristic callosities, but each foot was more consistent with moderate involvement with pain on manipulation and use since symptoms continued unabated even with arch support.  The rating, though, is 10% whether with unilateral or bilateral involvement thereby affording no additional benefit to the CI.  Alternatively, code 5284 (Foot injuries-moderate) does offer a rating option of 10% for each foot, but code 5399-5310 is more applicable for plantar fasciitis in the absence of documented injury or injuries and is pursuant with VASRD §4.3 (Resolution of reasonable doubt).  The Board determined that there was insufficient credible medical evidence that the bilateral pes planovalgus deformity was separately or independently unfitting, but did indeed antecede and contribute to the bilateral plantar fasciitis condition.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3, the Board recommends a disability rating of 10% for the right plantar fasciitis condition and a disability rating of 10% for the left plantar fasciitis condition.  Additionally, after due deliberation, considering all of the evidence and mindful of VASRD §4.3, the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the pes planovalgus deformity 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 right plantar fasciitis condition, the Board unanimously recommends a disability rating of 10%, coded 5399-5310 IAW VASRD §4.73 and in the matter of the left plantar fasciitis condition, the Board unanimously recommends a disability rating of 10%, coded 5399-5310 IAW VASRD §4.73.  In the matter of the pes planovalgus deformity 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.  

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

CONDITION	VASRD CODE	RATING	
Right Plantar Fasciitis	5399-5310	10%	
Left Plantar Fasciitis	5399-5310	10%	
COMBINED (w/ BLF)	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140518, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MEMORANDUM FOR COMMANDER, NAVY PERSONNEL COMMAND
DEPUTY COMMANDANT, MANPOWER & RESERVE AFFAIRS	
	                          
Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS          

Ref:  (a) DoDI 6040.44
(b) PDBR ltr dtd 21 Jan 16 ICO XXXXXXXXXXXXXXX  
(c) PDBR ltr dtd 07 Jan 16 ICO XXXXXXXXXXXXXXX
(d) PDBR ltr dtd 22 Jan 16 ICO XXXXXXXXXXXXXXX
(e) PDBR ltr dtd 11 Jan 16 ICO XXXXXXXXXXXXXXX
(f) PDBR ltr dtd 19 Jan 16 ICO XXXXXXXXXXXXXXX

1.  Pursuant to reference (a), the recommendations of the Physical Disability Board of Review set forth in references (b) through (k) are approved.

2.  The official records of the following individuals are to be corrected to reflect the stated disposition:

     a. XXXXXXXXXXXXXXX, former USMC: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge.

     b. XXXXXXXXXXXXXXX, former USN: Entitlement to disability separation pay with a 20 percent disability rating (increased from 0 percent) effective date of discharge.

     c. XXXXXXXXXXXXXXX, former USMC: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge.

     f. XXXXXXXXXXXXXXX, former USN: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge.

     e. XXXXXXXXXXXXXXX, former USN: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge.
     
3.  Please ensure all necessary actions are taken to implement these decisions, including the recoupment of disability severance pay, if warranted, and notification to the subject members once those actions are complete.

	XXXXXXXXXXXXXXX
	Assistant General Counsel
	(Manpower & Reserve Affairs)