RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  xxxxxxxxxxxxxxxxxxxx	CASE:  PD -2014-03689
BRANCH OF SERVICE:  Navy	Separation Date:  20030131

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-3 (Radio Frequency Equipment Operator) medically separated for a bilateral foot condition.  The condition could not be adequately rehabilitated to meet the physical requirements of his Rating.  He was placed on limited duty (LIMDU) and referred for an Medical Evaluation Board (MEB).  Bilateral plantar fasciitis, bilateral sinus tarsi/tarsal tunnel syndrome, and tarsometatarsal pain were forwarded to the Physical Evaluation Board (PEB) IAW SECNAVINST 1850.4E.  No other condition was submitted by the MEB.  The Informal PEB adjudicated bilateral plantar fasciitis as unfitting, rated 20% or 10% for each foot with application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The remaining conditions were determined to be Category II (conditions that contribute to the unfitting condition).  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 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 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:

IPEB - Dated 20021003	VA* - (~1 Mos. Pre-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Plantar Fasciitis	5399-5310	10%	Bilateral Plantar Fasciitis with Sinus Tarsal Tunnel Syndrome, and Tarsometatarsal Pain	5299-5276	10%	20021223	
	5399-5310	10%					
Tarsometatarsal Pain	Category II					
Bilateral Sinus Tarsi/Tarsal Tunnel Syndrome	Category II					
Other MEB/PEB Conditions x 0 (Not In Scope)	Other x 2	
RATING:  20%	RATING:  10%	
*Derived from VA Rating Decision (VARD) dated 20030117 (most proximate to date of separation [DOS])

ANALYSIS SUMMARY:  The tarsometatarsal pain and bilateral sinus tarsi/tarsal tunnel syndrome conditions (Category II) will be discussed under the unfitting bilateral plantar fasciitis condition below, as the three foot pain conditions are not separable for rating considerations.  

Bilateral Plantar Fasciitis Condition with Tarsometatarsal Pain and Bilateral Sinus Tarsi/Tarsal Tunnel Syndrome.  The CI developed bilateral foot pain mainly localized to the arch region (over the plantar fascia and metatarsals) in March 2001.  A left foot X-ray showed a stress fracture of the third toe.  A bone scan done in May 2001 showed significant uptake in the bases of the right and left third metatarsals as well as mild uptake of the distal tibial shaft (shin bone) on the left.  The CI continued to report painful feet and heels and falling on ambulation.  He was placed on an 8-month LIMDU for bilateral 3rd metatarsal stress fractures with specific restrictions of activity modification, no PRT, no running, no prolonged standing, no jumping, no ladders, no lifting greater than 10 pounds and no shipboard duty or deployment.  The orthopedist in August 2001 noted bilateral tenderness to palpation (TTP) at the insertion of the plantar fascia and 2nd metatarsal base, and tight heel cords.  The CI was given a steroid injection in both heels at this visit.  The neurologist in February 2002 documented physical exam findings of normal strength and reflexes bilaterally in the lower extremities, with an ability to stand on toes and heels.  The examiner noted a very subtle limp on the left foot.  An electromyogram done in February 2002 demonstrated a mildly abnormal study; however there was no evidence of neuropathy or myopathy.  The orthopedist in February 2002 noted some bilateral TTP of the tarsal sinus fascia.

The MEB narrative summary (NARSUM) exam performed approximately 7 months prior to separation documented that the CI reported that despite new orthotics (shoe inserts), extensive physical therapy, non-steroidal anti-inflammatory medications, night splints, and steroid injections, the CI continued to have pain along the plantar fascia on both feet.  The MEB NARSUM physical exam findings are summarized in the chart below.

The VA Compensation and Pension (C&P) exam performed approximately a month prior to separation documented that the CI reported daily foot pain (rated at 3-4/10) and that he was unable to walk or stand for long periods of time.  The examiner opined that the CI appeared to have a mild to moderate functional impairment.  The VA C&P physical exam findings are summarized in the chart below.  There were range-of-motion (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.

Ankle ROM
(Degrees)	MEB ~7 Mo. Pre-Sep	VA C&P ~1Mo. Pre-Sep	
	Left	Right	Left	Right	
Dorsiflexion (20 Normal)	10	10	No ROM	
Plantar Flexion (45)	40	40		
Comment	Stable ankle ligaments; mild tender in tarsal tunnel region medially; increased pain stretching plantar fascia	Mild tenderness to palpation (TTP) plantar aspects close to insertion into calcaneus; slight TTP dorsal aspect 3rd, 4th metatarsal area	
§4.71a Rating	10% L + 10% R (20%)	10%	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB coded the bilateral plantar fasciitis condition as 5399 analogous to 5310 (Group X. Function:  Movements of forefoot and toes; propulsion thrust in walking) and rated at 10% (moderate) for each side (combined 20%) with tarsometatarsal pain and bilateral sinus tarsi/tarsal tunnel syndrome conditions as contributing conditions.  The VA coded the bilateral plantar fasciitis with sinus tarsal tunnel syndrome and tarsometatarsal pain conditions as a combined entity using 5299 analogous to 5276 (Flatfoot, acquired) and rated at 10% [moderate – pain on manipulation and use of the feet (bilateral)”].

Both the MEB and C&P exams documented pain in the plantar fascia and metatarsal area and pain on manipulation of the feet.  The Board agreed that the disability from the unfitting plantar fasciitis and the Category II conditions overlapped and that IAW VASRD §4.14 (Avoidance of pyramiding) the pain symptoms could not support any dual rating.  There was not sufficient evidence of a “moderately severe” muscle injury on either foot IAW VASRD §4.73 (Schedule of ratings–muscle injuries) to warrant higher than a 10% rating for each foot.  There was no objective evidence of foot deformity, swelling or characteristic callosities of the feet for any higher rating under 5276, or support for any other higher disability rating under §4.71a (Schedule of ratings–musculoskeletal system).  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 bilateral plantar fasciitis 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 (and associated Category II conditions) and IAW VASRD §4.73, 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, 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 20140710, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MEMORANDUM FOR DIRECTOR, SECRETARY OF THE NAVY COUNCIL OF REVIEW
               BOARDS 

Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS
 
Ref:   (a) DoDI 6040.44
       (b) CORB ltr dtd 2 Dec 15

      In accordance with reference (a), I have reviewed the cases forwarded by reference (b), and, for the reasons provided in their forwarding memorandums, approve the recommendations of the PDBR that the following individual’s records not be corrected to reflect a change in either characterization of separation or in the disability rating previously assigned by the Department of the Navy’s Physical Evaluation Board:

- XXXXXXXXXXXXXXXXXXXX former USN  
- XXXXXXXXXXXXXXXXXXXX former USN 
- XXXXXXXXXXXXXXXXXXXX former USN
- XXXXXXXXXXXXXXXXXXXX former USN
- XXXXXXXXXXXXXXXXXXXX former USN
- XXXXXXXXXXXXXXXXXXXX former USN
- XXXXXXXXXXXXXXXXXXXX former USN
- XXXXXXXXXXXXXXXXXXXX former USN
- XXXXXXXXXXXXXXXXXXXX former USN
- XXXXXXXXXXXXXXXXXXXX former USN

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	     				  Assistant General Counsel
						  (Manpower & Reserve Affairs)