RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03829
BRANCH OF SERVICE:  Army	BOARD DATE:  20150415
SEPARATION DATE:  20051022

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-3 (Supply Specialist) medically separated for bipolar-1 disorder and bilateral plantar fasciitis.  The mental health (MH) and foot conditions could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty (MOS) or satisfy physical fitness standards.  She was issued a permanent L3,S3 profile and referred for a Medical Evaluation Board (MEB).  The “chronic bilateral foot pain/plantar fasciitis” and “bipolar-1 disorder,” were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also identified and forwarded five other conditions (see rating chart below) for PEB adjudication.  The Informal PEB adjudicated “bipolar-1 disorder and bilateral plantar fasciitis” as unfitting, rated 10% and 0% respectively, with likely application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The remaining conditions were determined to be not unfitting. 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 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 20050916	VA* - (~11 Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bipolar I Disorder	9432	10%	Bipolar Disorder with Anxiety Disorder	9413-9432	30%	20060911	
Bilateral Plantar Fasciitis	5399-5310	0%	Bilateral Plantar Fasciitis	5299-5276	10%	20060911	
Chronic Intermittent Low Back Pain	Not Unfitting 
	Lumbar Strain with Thoracic Spine Pain	5237	0%	20060911	
Chlamydia Cervicitis		Chlamydia	7699-7611	NSC	20060911	
Abnormal Pap		Human Papilloma Virus	7699-7612	NSC	20060911	
Thrombocytosis		Thrombocytosis	7199-7121	NSC	20060911	
Smoking		No VA Placement	
Other x 0 (Not In Scope)	Other x 3 	
RATING:  10%	RATING:  50%	
*Derived from VA Rating Decision (VARD) dated 20061027 (most proximate to date of separation [DOS]).

ANALYSIS SUMMARY:

Bipolar I Disorder Condition.  The psychiatry narrative summary (NARSUM), dated 19 July 2005, 3 months prior to separation, documented the CI initially presented to MH in February 2005 for symptoms of depression, anxiety and insomnia.  At the time of her initial presentation, she was in the MEB process for issues related to her feet, and was ambivalent about the MEB.  The CI reported she had marital problems; and both the feet and marital issues had caused depression and anxiety symptoms.  The CI was in the process of a divorce.  She was scheduled to return for treatment on 31 March 2005 but was non-attendant.  It is not clear when she began treatment; however, the NARSUM recorded the CI was seen for medication management and was prescribed medication for mood stability and an antidepressant.  She reportedly discontinued the medication after 2 months and as a result her mood swings and irritability increased.  On 21 July 2005, the CI presented to MH and restarted her medication; the nurse practitioner prescribed an additional mood stabilizer to her medication regimen.  At the NARSUM, the CI noted she had mood swings while she was in Advanced Individual Training (AIT), and as a teenager, she attended counseling for 2 years related to her mother being in prison and drug rehabilitation.  The CI reportedly stated that her mother has bipolar disorder and she suspected that her twin sister (CI’s twin) also have bipolar disorder.  Mental status exam (MSE) documented rapid and pressured speech, and noted that she appeared anxious.  Mood, affect, cognition, insight and judgment were not recoded.  The CI reportedly described her usual pattern of mood swings as being in a hypomanic state for 6-12 hours, followed by a depressed mood for 1 to 2 hours.  She has crying spells approximately once a week with anhedonia, social withdrawal, and feelings of helplessness and hopelessness.  She has racing thoughts, irritability, daily stomachaches and a decrease in appetite with some weight loss.  The examiner diagnosed Bipolar I disorder, and borderline and dependent personality features.  A Global Assessment of Functioning (GAF) score of 60 (borderline moderate-mild) was assessed, and the examiner opined a favorable prognosis with continued treatment.  Level of social and occupational impairment was not documented; however, the examiner opined that the CI’s diagnosis was unfitting for military duty.

At the VA Compensation and Pension (C&P) MH exam performed on 11 September 2006, 11 months after separation, the CI reportedly stated her mood disorder and feet problem began during her deployment (DD 214 recorded no deployments).  She related her marital problems to the problems she had experienced at work with a member of her unit.  The CI also indicated that she was still in divorce proceeding, and reported she had been in regular MH treatment from September 2004 to September 2005 (treatment records not among evidence).  She had not continued MH treatment beyond September 2005 and was not taking psychotropic medication at the time of the examination.  The CI had been unemployed for seven months post-separation, but had current employment in a department store.  MSE documented slightly irritable mood, minor difficulties with attention, focus and memory, but she was generally intact cognitively.  The CI reported occasional panic attacks, daily irritability and sleep disturbance.  She denied psychotic symptoms, suicidal and homicidal ideation and did not have a history of suicidal attempts, emergency room treatment or psychiatric hospitalization.  The examiner noted that the CI had not reported any significant absences from her job of 45 days, and had not had any work related issues but noted there had been some tension with customers, coworkers and supervisors.  The diagnoses of bipolar disorder II, and anxiety disorder NOS were assessed with personality disorder NOS and a GAF of 59 (moderate symptoms or impairment).

The Board directed its attention to the rating recommendation based on the evidence just described.  The PEB rated the condition at 10%, coded 9432.  The VA rated the condition of bipolar disorder with anxiety disorder at 30%, coded 9413-9432.  Both the NARSUM and the C&P examinations reported similar MSEs and GAF scores.  The NARSUM examination did not describe impairment in social or occupational functioning, and assigned a GAF of 60 (borderline moderate to mild), 3 months prior to separation.  At the time of separation the Board agreed that the §4.130 threshold for a 50% rating (occupational and social impairment with reduced reliability and productivity) was not approached.  A rating of 30% requires “occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks.”  The records noted absence of psychiatric hospitalization, no recorded panic attacks, essentially normal MSEs (NARSUM, C&P) minimal use of psychotropic medication and counseling, and absence of documented duty impairment.  The MH condition was not implicated in the commander’s statement.  The Board acknowledged the VA examination, 11 months after separation that suggested that the CI’s condition had worsened; however, there was absence of hospitalization and emergency room visits; the CI was employed, was not taking medication, and was psychiatrically stable.  All Board members agreed that the 30% rating was not supported by the evidence at hand.  The 10% description, “occupational and social impairment due to mild or transient symptoms which decrease work efficiency only during periods of significant stress, or; symptoms controlled by continuous medication,” more accurately reflects the CI’s condition at separation.  All evidence considered there is not reasonable doubt in the CI’s favor supporting a change from the PEB’s rating decision for the Bipolar I condition.  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 Bipolar I condition.

Bilateral Plantar Fasciitis Condition.  The Orthopedic NARSUM dictated 13 June 2005 noted the CI presented to the podiatry clinic in May 2005 for evaluation of her feet.  She provided a 10-month history of bilateral plantar fasciitis, and stated her pain began prior to graduating AIT, August 2004.  Her pain was described as throbbing, dull and constant 5/10 intensity.  The CI also reported numbness and tingling in her toes.  Her pain prohibited her ability to march, ruck, jog, and run; she denied any trauma to her feet.  She was treated conservatively with non-steroidal anti-inflammatories, arch support, night splints, and exercises with minimal improvement.  Focused physical examination of both feet revealed tenderness to palpation over the plantar medial heel and the plantar medial longitudinal arch.  A normal medial arch was appreciated.  Mild tenderness to palpation of the dorsal aspect of both feet was noted.  There was tenderness to range-of*motion of the ankle joint with pain radiating to the plantar aspect of both feet.  The physician documented the absence of abnormal findings on the EMG and nerve conduction studies, and that radiographs of both feet were normal.  The diagnosis of chronic plantar fasciitis of both feet was recorded, and the physician noted that the CI was unable to perform her MOS duties due to her feet condition.  The NARSUM dated 30 August 2005, recorded a history of non-traumatic chronic foot pain, and that the CI first sought treatment during basic training and was diagnosed with plantar fasciitis.  Treatment records were not in evidence.  Bilateral feet radiographs dated 1 November 2004, and 7 February 2005 were normal.  The NARSUM examiner documented that the MEB physical exam performed in June 2005 recorded no significant findings; however, referred to DD 2808 and 2807 for “details.”  Review of DD 2808 and 2807 documented the report of numbness and tingling in bilateral feet and sharp, constant pain at rest that worsened with increased activity and standing.  The examination did not document gait, tenderness to palpation, neurological or motor status, but assessed the CI with chronic foot pain.  The profile restricted running, and allowed unlimited biking and swimming, upper and lower body weight training, and walking at own pace and distance.  The CI reported pain in both feet at intensity of 5/10 that increased with activities and prolonged standing.  The commander’s statement opined that the CI was “unable to effectively serve in her current MOS or any MOS in the Army.  With the high demands for deployment and field training, she is no longer suited for military service.”  There were no treatment records in evidence that documented one foot being worse than the other.

At the VA C&P evaluation on 11 September 2006, approximately 11 months after separation; physical examination recorded a normal gait, and absence of the use of assistive device.  The CI could heel and toe walk without difficulty; neurological and muscle strength examinations were normal, and there was minimal pain to palpation over the bilateral heels.  Abnormal shoe wear pattern was absent.  The examiner documented the absence of flatfoot, hammertoes, or other deformities.  There was no report of one foot being more symptomatic than the other foot.  The diagnosis of bilateral plantar fasciitis, mild was recorded.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB combined the foot condition recorded as chronic bilateral foot pain secondary to plantar fasciitis, rated analogously coded 5399-5310 (Group X) muscle injury at 0% for slight.  The VA rated the condition at 10% coded analogously 5299-5276 (flatfoot, acquired).  The Board first considered if each foot could be reasonably justified as separately unfitting.  The Board noted there were no entries in the treatment record that addressed the foot separately; the NARSUM and MEB opined both foot were unfitting without reference to one foot being worse than the other.  The Board determined the record in evidence did not reasonably support that either foot were separately unfitting; however, taken in combination, the condition was unfitting.  The Board agreed separate ratings were not supported by the evidence at hand.  A 10% evaluation under the 5310 code requires objective evidence of moderate impairment involving movement of feet or toes due to muscle dysfunction or plantar fascia/ligaments.  The available evidence does not support a higher rating under this code.  The Board noted the only clinical finding was bilateral tenderness, recorded at both C&P and MEB examination and the absence of documented pain on motion at the NARSUM.  The Board noted code 5276 (flatfoot) was not applicable since the CI had a normal arch, and the 5279 code (Metatarsalgia, anterior) was not supported by the evidence.  There were no additional coding options applicable to the rating of this condition.  The Board deliberated the application of § 4.40 and §4.59 and agreed the record sufficiently documented the condition was compensable under §4.59.  The orthopedic NARSUM documented tenderness on manipulation of the ankle with pain radiating to the bilateral plantar feet, prolonged standing worsened her pain, and her pain was refractory to treatment.  Thereupon, after due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10%, under §4.59 for the bilateral foot condition.

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that the conditions of chronic intermittent low back pain, history of chlamydia cervicitis, history of abnormal PAP and history of thrombocytosis, and smoking 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 above noted conditions were not profiled or implicated in the commander’s statement and were not judged to fail retention standards.  All were reviewed and considered by the Board.  There was no performance based evidence from the record that any of these 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 any of the contended conditions and so no additional disability ratings are 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 Bipolar I condition and IAW VASRD §4.130a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the bilateral plantar fasciitis condition, the Board unanimously recommends a disability rating of 10%, coded 5299-5310 IAW VASRD §4.71a.  In the matter of the contended chronic intermittent low back pain, history of chlamydia cervicitis, history of abnormal PAP, history of thrombocytosis, and smoking conditions, the Board unanimously recommends no change from the PEB determinations as not unfitting.  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	
Bipolar Disorder I	9432	10%	
Bilateral Plantar Fasciitis	5299-5310	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140820, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAMR-RB										

MEMORANDUM FOR Commander, US Army Physical Disability Agency 
(AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation 
for XXXXXXXXXXXXXXXXXX, AR20150018862 (PD201403829)

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,   I accept the Board’s recommendation to modify the individual’s disability rating to 20% without recharacterization 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