RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03315
BRANCH OF SERVICE:  AIR FORCE	BOARD DATE:  20150113
Separation Date:  20090728

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (Aerospace Propulsion Journeyman) medically separated for bilateral plantar fasciitis and chronic low back pain (LBP).  These conditions could not be adequately rehabilitated to meet the physical requirements of his Air Force Specialty (AFS) or satisfy physical fitness standards.  He was issued a duty limiting condition report and referred for a Medical Evaluation Board (MEB).  The MEB forwarded “recalcitrant plantar fasciitis” and “LBP” to the Physical Evaluation Board (PEB) IAW AFI 44-113, 36-3212, and 48-123.  No other conditions were submitted by the MEB.  The PEB adjudicated the bilateral plantar fasciitis and chronic LBP as Category I (unfitting conditions which are compensable and ratable).  Citing criteria of the VA Schedule for Rating Disabilities (VASRD), the PEB rated each condition at 10% disabling, for a 20% combined disability.  Although not referred by the MEB, the PEB also adjudicated “adjustment disorder with depressed mood” as Category III: condition(s) that are not separately unfitting and not compensable or ratable.  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 (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 IPEB – Dated 20090612	VA - (3 Mos. and 9 Mos. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Plantar Fasciitis	5020	10%	Plantar Fasciitis, Left Foot	5284	10%	20091030	
			Plantar Fasciitis, Right Foot	5284	10%	20091030	
Chronic LBP	5237	10%	Lumbar and Mid Back Strain	5243-5237	Deferred*	
Adjustment Disorder	Not Unfitting	Adjustment Disorder	9440	Deferred*	
Other x0	Combined:  40%	
Combined:  20%		
Derived from VA Rating Decision (VARD) dated 20100408 (most proximate to date of separation [DOS])

ANALYSIS SUMMARY:  The PEB rated bilateral plantar fasciitis under the single code 5020 Synovitis code.  This coding approach is countenanced by AR 635-40 (B.24 f.), but IAW DoDI 6040.44 the Board must apply only VASRD guidance to its recommendation.  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 disability rating.

Bilateral Plantar Fasciitis Condition.  The CI developed bilateral foot pain in 2006.  A bilateral foot X-ray was normal.  A physical therapy (PT) evaluation documented tenderness to palpation (TTP) over bilateral fascia and diagnosed bilateral plantar fasciitis.  A month later, the CI reported to the PT that his right foot normally hurt more than his left foot; however the pain was equal on this date.  He further reported that after receiving treatment, he would be pain free for 24 hours.  The CI was prescribed foot orthoses, stretching exercises, phonophoresis, aerobic exercises, ice and massage; however, he was not compliant with the night splints, ice, massage, exercise, and stretching.  The PT again advised him on being compliant to reduce pain symptoms.  The Primary Care examiner noted bilateral foot and heel pain when standing.  There were physical exam findings of bilateral plantar TTP.  The bilateral foot X-ray showed a mild right hallux valgus (bunion) with approximately 17-18 degrees of angulation.  There was no comment on the left foot.  The neurologist documented that the daily throbbing, burning bilateral foot pain was worse at the end of the day, provoked by prolonged standing.  The CI described the pain as excruciating 9/10, mostly in the heel, but sometimes in the arches involving the underside of the feet.  There were physical exam findings of tender points on his heels.  A nerve conduction velocity performed on 11 February 2011 was normal.  There was no evidence of tarsal tunnel or generalized neuropathy.  The CI underwent a bilateral foot Ossatron procedure (a high energy shock wave done for plantar fasciitis to increase blood flow and stimulate the affected heel) on 1 August 2008.  The podiatrist documented that the CI’s feet were still severely hurting him, despite the Ossatron procedure.  The podiatrist noted bilateral TTP over the insertion of the medial band of the plantar fascia.  The examiner advised the CI that he had recalcitrant plantar fasciitis and the next step in treatment could be endoscopic surgery.  The MEB narrative summary (NARSUM) exam performed approximately 8 months prior to separation documented that the CI had sharp throbbing bilateral plantar fasciitis pain after standing for more than 15 minutes.  The MEB NARSUM physical exam findings are summarized in the chart below.  The commander’s statement indicated that the CI could not perform his AFS duties in a deployed location due to his physical disabilities, yet gave the following written response to the question:

“Does the member's medical condition impact your ability to perform your in-garrison/deployed mission? If so, how?

ANSWER: In garrison, his condition does not impact my ability to perform my mission.  However, unless his condition is fixed, he cannot support my deployed mission.”

The CI was given a “duty limiting condition report” with restrictions of no running, no prolonged walking, and no lifting greater than 15 pounds, no crunches, and no push-ups (no condition was identified).  The NARSUM provider’s final diagnosis/recommendation was the following:

“Recalcitrant Plantar Fasciitis- Failed multiple modalities of treatments.  He is, however, able to do his duty without limitation.  Refer to IPEB for further evaluation.”

The VA Compensation and Pension (C&P) exam approximately 3 months after separation documented pain mostly at the heels and arches in both feet.  The examiner made a point of documenting that there “were no Waddell’s signs or symptom magnification behaviors.”  The VA C&P physical exam findings are summarized in the following chart.

There was one range-of-motion (ROM) evaluation in evidence, with documentation of additional ratable criteria, which the Board weighed in arriving at its rating recommendation; as summarized in the chart below.

Ankle ROM (Degrees)	MEB ~8.5 Mos. Pre-Sep	VA C&P ~3 Mos. Post-Sep	
	Left	Right	Left	Right	
Dorsiflexion (20 Normal)	No ROM’s	Normal	Normal	
Plantar Flexion (45)		Normal	Normal	
Comment	Normal gait, balance & sensation; Pos. tenderness to palpation(TTP) insertion of plantar fascia	Antalgic gait; TTP plantar fascia; Normal sensation, reflexes & strength; Pos. flat feet; No Deluca criteria	
§4.71a Rating	10%	(VA 10%/10%)	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB coded the bilateral plantar fasciitis condition as 5020 (synovitis) and rated at 10%.  The VA separately coded and rated each foot condition as plantar fasciitis, left and right foot conditions both coded as 5284 (other foot injuries) and both rated at 10%, moderate.  As noted above, there were no unilateral distinctions with regards to clinical features or fitness considerations.  Evidence in the record does not reasonably justify a conclusion that the disability confined to a single foot would have rendered the CI incapable of performing his AFS; and it is reasonable to surmise that it was the disability of both feet together which rendered him unfit.  Furthermore, the bilateral diagnosis is supported under a single 5003 VASRD code for two or more major joints; thus there is VASRD §4.71a latitude for a bilateral rating.  Members agreed therefore, that there were insufficient grounds for recommending separate right and left foot disability ratings in this case.  There was no specific injury noted, both exams documented non-compensable ankle ROM, and the evidence provides adequate support for painful motion IAW §4.59.  Under VASRD code 5003:

“When however, the limitation of motion of the specific joint or joints involved is non-compensable under the appropriate diagnostic codes, a rating of 10 pct. is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under diagnostic code 5003.  Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion.”

After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt) and §4.40 (functional loss), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the bilateral plantar fasciitis condition.

Chronic LBP Condition:  The CI developed immediate LBP in 2006 after he tried to push a trailer into a hangar.  A lumbar spine X-ray was normal.  A lumbar spine magnetic resonance imaging showed a mild bulging L5-S1 intervertebral disc encroached on the left S1 nerve root without impingement.  The chiropractor documented low back stiffness, knife like pain that could last 1 to 2 hours without radiation.  There were physical findings of TTP, and abnormal extension.  The lumbar spine X-ray showed a loss of the normal lumbar curvature.  The MEB NARSUM exam approximately 8 months prior to separation documented that the CI reported a feeling that his back would “buckle” and pain would shoot sideways and occurred “maybe twice a month” and was rated at 9/10. The MEB NARSUM physical exam findings are summarized in the chart below.  The Family Practitioner noted that bending forward and lying flat would exacerbate his pain.  There were physical exam findings of TTP of the paraspinal muscles and forward flexion was limited to pain and poor flexibility.  The CI underwent thoracic spine X-rays in May and June 2009 which were normal.  The PT noted that the CI had aching and shooting mid and lower back pain with difficulty maintaining balance during an exacerbation.  The physical exam findings are summarized in the chart below.  The commander’s statement indicated that the CI missed 5 days of work and could not perform his AFS duties due to his physical disabilities.  The CI was given a profile with restrictions of no running, no prolonged walking, and no lifting greater than 15 pounds, no crunches, and no pushups.  The VA C&P exam approximately 3 months after separation documented pain was exacerbated by lying on soft surfaces, sitting and walking, side bending increased the pain and the pain was worse at night.  He would have intermittent back spasms when he would walk and he would need to sit for 20 minutes and then continue.  He also experienced daily back stiffness following repetitive motion and sharp repetitive punching pain sensation.  The VA C&P physical exam findings are summarized in the following chart.

There were two ROM evaluations in evidence, with documentation of additional ratable criteria, which the Board weighed in arriving at its rating recommendation; as summarized in the chart below.

Thoracolumbar ROM (Degrees)	MEB ~8.5 Mos. Pre-Sep	VA C&P ~3 Mos. Post-Sep	
Flexion (90 Normal)	FROM	70	
Combined (240)	240	160	
Comment	Normal gait; Pos. muscle tightness and tenderness; Normal sensation, strength & reflexes	Gait slower than normal; Pos. painful motion & muscle spasm; Pos. Deluca criteria; No Waddell’s	
§4.71a Rating	10% (PEB 10%)	10% (VA deferred)	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB coded the chronic LBP condition as 5237 (lumbosacral or cervical strain) and rated at 10%.  The VA coded the lumbar and mid back strain condition as 5243 (intervertebral disc syndrome) with 5237 and the rating was deferred.  On 8 June 2010, the VARD rated the back condition at 10% effective 29 July 2009.  The “General Rating Formula for Diseases and Injuries of the Spine” considers the CI’s pain symptoms “with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease.”  The CI had documentation of tenderness and muscle tightness (which the Board concluded was synonymous with spasm) on the MEB exam which met the 10% rating criteria of “muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour.”  There was no documented evidence of a separate functional neurologic deficit resultant from the CI’s back condition.  The C&P exam also met the 10% rating criteria based on the documented ROM measurement.  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 chronic LBP condition.

Adjustment Disorder with Depressed Mood Condition.  The contended condition adjudicated as a Category III (“Conditions that are not separately unfitting and not compensable or ratable”) was adjustment disorder with depressed mood.  The Board’s first charge with respect to these conditions is an assessment of the fitness based on a preponderance of evidence.  No mental health (MH) condition was discussed in the MEB NARSUM, listed by the MEB and the PEB adjudicated the adjustment disorder diagnosis as a Category III condition.  The Family Practitioner in October 2008 noted that the CI was depressed due to his MEB status and there were no psychiatric emergency visits, no hospitalizations and suicidal or homicidal ideations.  The profile did not specify any restrictions related to an MH condition, and no MH condition was implicated in the commander’s statement, or was judged to fail retention standards.

The Board determined that there was no indication from the record that any MH 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 determination of unfit for a contended MH condition; and, therefore, no additional disability rating can be recommended.

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 and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the chronic LBP condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the adjustment disorder with depressed mood contended condition, the Board unanimously recommends no change from the PEB determination as not unfitting.  There were no other conditions within the Board’s scope of review for consideration.

RECOMMENDATION:  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 20140630, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

SAF/MRB
1500 West Perimeter Road, Suite 3700
Joint Base Andrews, MD  20762

Dear XXXXXXXXXX:

	Reference your application submitted under the provisions of DoDI 6040.44 (Title 10 U.S.C. §  1554a), PDBR Case Number PD-2014-03315.

	After careful consideration of your application and treatment records, the Physical Disability Board of Review determined that the rating assigned at the time of final disposition of your disability evaluation system processing was appropriate.  Accordingly, the Board recommended no re-characterization or modification of your separation.

	I have carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding and their conclusion that re-characterization of your separation is not warranted.  Accordingly, I accept their recommendation that your application be denied.

							Sincerely,

Attachment:
Record of Proceedings