RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03358
BRANCH OF SERVICE:  Marine Corps 	SEPARATION DATE:  20041031

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3, Motor Transport Operator, medically separated for “chronic plantar fasciitis”, with a disability rating of 10%.

CI CONTENTION:  The CI requested consideration of all conditions.  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 - 20040831	VARD - 20041207	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Plantar Fasciitis	5399-5310	10%	Mild Pes Planus w/Chronic Plantar Fasciitis, Right Foot	5099-5020	10%	20040927	
			Mild Pes Planus w/Chronic Plantar Fasciitis, Left Foot	5099-5020	10%	20040927	
Pes Planus	Cat II	See Above	
Hallux Limitus	Cat III	No VA Entry	
Hallux Limitus/Hallux Valgus	Cat III	Hallux Valgus, Claimed As Bilateral Bunions	5280	0%	20040927	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  50%	

ANALYSIS SUMMARY:  

Chronic Plantar Fasciitis.  The service treatment records (STRs) and the MEB narrative summary (NARSUM) indicated the CI had a longstanding diagnosis of plantar fasciitis, the first note of which in the STR dated 14 August 2002 documented the CI’s left leg was 0.9 cm shorter than the right and he had plantar fasciitis of the left foot that was treated with an injection of lidocaine (an anesthetic).  On 12 September 2002, the CI was diagnosed with plantar fasciitis bilaterally, Achilles tendonitis with Haglund’s deformity (bony enlargement on the back of the heel) and pes planovalgus bilaterally.  Treatment consisted of stretching, custom splints and an anti-inflammatory drug.  In January 2003 surgery for the plantar fasciitis was deferred pending deployment.  Post-deployment custom orthotics were selected rather than surgery; however, symptoms migrated proximally around the medial heel, which required modification of the orthotics.  In May 2004 pain persisted and the CI was referred to physical therapy.  In June 2004 the central compartment of the feet deep to the central plantar fascial band was prominent and very tender.  Dangling of the feet produced distal tingling raising the diagnosis of secondary tarsal tunnel syndrome.  The chronic plantar fasciitis with pes planus was not responsive to conservative therapy including nonsteroidal anti-inflammatory drugs (NSAIDS), steroid injections, night splints, custom molded orthotics, physical therapy or limited duty.  The NARSUM examiner noted a collapsing flat foot, hallux valgus (bunion) with hallux limitus (toe stiffness) at the forefoot, and a positive Tinel’s sign (to determine nerve irritation) on percussion of the left tibial nerve.  The CI had adequate posterior tibial tendon strength and chronic tightness of the calves producing a gastrocsoleus equinus (producing ankle joint restriction) of both lower extremities.  There was a positive Tinel’s on the percussion of the tibial and deep peroneal nerve on the contralateral foot as well.  The central compartment and the central band of the plantar fascia was chronically tender, very taut, with no evidence of ecchymosis.  X-ray findings were consistent with pes planus foot type and there was no evident spur. Magnetic resonance imaging (MRI) images revealed small vascular structures entering the plantar foot; however, there were no abnormal masses or tissue damage.

At the MEB examination on 20 August 2004, the CI reported he had used orthotics since 2002, had flat feet and was advised to have foot surgery.  The MEB physical examiner noted normal arches and the CI used orthotics.  

At the VA Compensation and Pension (C&P) examination dated 27 September 2004, performed 1 month before separation, the CI reported chronic pain even after standing for longer than 5 minutes.  His feet constantly ached and throbbed.  The CI’s gait and stance were normal and was able to walk on his heels and toes and to hop on alternate legs as well as to perform repetitive squatting without difficulty.  Examination of the right foot revealed no tenderness, weakness, edema, atrophy or disturbed circulation.  Examination of the left foot revealed no tenderness, weakness, edema, atrophy or disturbed circulation.  There was very mild bilateral pes planus or obvious joint deformities, bunions, or overlying skin wear changes.  The CI did not have any limitation with standing and walking and did not require any type of support with his shoes.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating using code 5399-5310 (Group X. Function:  Movements of forefoot and toes…plantar aponeurosis…) for the Category I chronic plantar fasciitis condition and determined the Category II pes planus condition was related to Category I condition.  The PEB determined that Category III hallux limitus and hallux limitus/hallux valgus conditions were not separately unfitting and do not contribute to the unfitting condition(s).  The VA assigned a 10% rating using code 5099-5020 (synovitis) for mild pes planus with chronic plantar fasciitis, right foot and a 10% rating using 5099-5020 for mild pes planus with chronic plantar fasciitis, left foot.   

Board Approach to PEB Consolidated Rating. The PEB combined the bilateral pes planus conditions as a single unfitting condition coded 5399-5310 with a rating of 10%. The approach by the PEB commonly reflected its judgment that the constellation of conditions was unfitting, and there was no need for separate fitness adjudications or implied adjudication that each condition was separately unfitting.  The Board’s initial charge in this case was directed at determining if the PEB’s approach of combining conditions under a single rating was justified in lieu of separate ratings.  When considering a separate rating for each condition, the Board considers each bundled condition to be reasonably justified as separately unfitting unless a preponderance of evidence indicates the condition would not cause the member to be referred into the DES or be found unfit because of physical disability.  When the Board recommends separate fitness recommendations in this circumstance, its recommendations may not produce a lower combined rating than that of the PEB.  The evidence for the bilateral pes planus conditions was presented together above.  Members agreed that each foot condition was reasonably justified as separately unfitting, albeit initial reports were directed toward the left foot; however, subsequent reports addressed the plantar fasciitis bilaterally; therefore, identical coding and ratings are applicable.  The Board first considered whether analogous code 5299-5276 (flatfoot, acquired) would provide additional benefit to the CI.  A moderate disability with pain on manipulation and use of the feet would capture the plantar fasciitis, but use of the code provides a rating of 10% for either bilateral or unilateral involvement; therefore, there would be no additional benefit to the CI with its use.  The Board then considered whether code 5399-5310 was applicable to each foot and determined it would be both reasonable and appropriate.  A higher rating could not be obtained in the absence of claw foot (code 5278), malunion or nonunion of the tarsal or metatarsal bones (code 5283), or moderately severe or severe foot injuries (code 5284).  The Board then determined that the Category II condition, pes planus bilaterally, contributed to the Category I condition, bilateral plantar fasciitis, and was not independently unfitting and was, therefore, noncompensable.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% for the left foot plantar fasciitis condition and a disability rating of 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 Category III conditions hallux limitus (loss of motion in the big toe) and hallux limitus/hallux valgus (bunion) were not unfitting.  The Board’s threshold for countering fitness determinations requires a preponderance of evidence, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.  The hallux limitus was not addressed in the limited duty medical report, but painful bunions were mentioned and along with plantar fasciitis were recommended for 8 months of limited duty; however, neither condition was implicated in the Non-Medical Assessment.  The NARSUM indicated that the hallux limitus likely existed prior to entry into the service and the hallux limitus/hallux valgus existed prior to enlistment (EPTE); however, since the limited duty report did list painful bunions, service aggravation for the hallux valgus can be presumed.  Nevertheless, there was no specific performance based evidence from the record that the 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 either of the contended conditions; and so, no additional disability ratings are recommended.

BOARD FINDINGS:  In the matter of the left plantar fasciitis condition, the Board unanimously or majority recommends a disability rating of 10%, coded 5399-5310 IAW VASRD §4.71a.  In the matter of the right plantar fasciitis condition, the Board unanimously or majority recommends a disability rating of 10%, coded 5399-5310 IAW VASRD §4.71a.  In the matter of the contended hallux limitus and hallux limitus/hallux valgus conditions, the Board unanimously or majority recommends no change from the PEB determinations as not unfitting.  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 medical separation:    

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

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140602, 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 27 Jul 16 ICO XXXXXXXXXXXXXXXXXXXX  
	(c) PDBR ltr dtd 27 Jul 16 ICO XXXXXXXXXXXXXXXXXXXX
	(d) PDBR ltr dtd 27 Jul 16 ICO XXXXXXXXXXXXXXXXXXXX 
	(e) PDBR ltr dtd 27 Jun 16 ICO XXXXXXXXXXXXXXXXXXXX 
	(f) PDBR ltr dtd 27 Jul 16 ICO XXXXXXXXXXXXXXXXXXXX

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

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

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

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

     c. XXXXXXXXXXXXXXXXXXXX, former USMC: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge.
 
     d. XXXXXXXXXXXXXXXXXXXX, former USN: Entitlement to disability separation pay with a 10 percent disability rating (increased from 0 percent) effective date of discharge.
     
     d. XXXXXXXXXXXXXXXXXXXX, former USMC: 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.

						XXXXXXXXXXXXXXXXXXXX
						Assistant General Counsel
						(Manpower & Reserve Affairs)