RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03841
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20090625

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Signal Support Systems Specialist, medically separated for “bilateral pes planus with plantar fasciitis,” with a disability rating of 10%.

CI CONTENTION:  The CI requests 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 - 20090326	VARD - 20100122	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Pes Planus with Plantar Fasciitis	5299-5276	10%	Plantar Fasciitis, Right Foot	5099-5020	10%	20090413	
			Plantar Fasciitis, Left Foot	5099-5020	10%	20090413	
			Bilateral Pes Planus	5276	10%	20090413	
Bilateral Patellofemoral Syndrome	Not Unfitting	Patellofemoral Syndrome, Left Knee	5299-5261	10%	20090413	
		Right Knee Condition	5299-5261	10%	20090413	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Bilateral Pes Planus with Plantar Fasciitis.  According to service treatment records (STRs) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s bilateral plantar foot pain began in June 2004 after a period of heavy running and ruck marches, the left heel of which was worse with his first steps in the morning.  He was diagnosed with bilateral plantar fasciitis and over time was treated with customized orthotics, steroid injections and night splints with some relief and was given an L2 profile for no running.  During deployment in 2006-2007 the condition worsened.  Piroxicam, a nonsteroidal anti-inflammatory drug (NSAID) was prescribed in December 2007 for the bilateral plantar fasciitis.  X-rays of the feet in December 2007 showed slight irregularity of the navicular bone on the left, which may have represented sequelae of trauma.  No other significant abnormalities were seen and no calcaneal spurs were demonstrated.  On 30 January 2008 the CI had plantar release surgery of the left foot, which had worse pain was not responsive to medication.  Postoperatively he denied difficulty with the surgical site or incision, but had continued heel and radiating pain into his leg with running.  He denied difficulty with standing; however, did have stiffness after sitting for a prolonged time.  Ice, massage, and stretching were recommended along with a new profile.   Weight bearing X-rays in July 2008 demonstrated bilateral moderate pes planus deformity.  Based on the outcome of the left foot surgery, the CI decided not to have a right plantar release done.  The CI performed stretching exercises on his own time with short-term relief.  After several temporary profiles and failure of conservative treatment including medication (Tylenol #3 (acetaminophen, a pain reliever and codeine, a narcotic) and amitriptyline (for nerve pain)), and surgery, the CI was referred for a MEB in August 2008.  

At the MEB examination dated 7 November 2008, approximately 7 months prior to separation, the CI reported bilateral plantar fasciitis and the condition prevented him from walking, running and sitting for long periods of time.  The examiner noted tenderness of both feet due to the chronic plantar fasciitis.  The NARSUM physical examination dated 12 January 2009 revealed tight heel cords bilaterally without tenderness to palpation on either foot.  There was mild-moderate pes planus with weight bearing, but visible arches when not weight bearing.  The CI had an antalgic gait and he had a surgical scar on the medial surface of the left foot anterior to the medial malleolus.  Range of motion (ROM) measurements in January 2009 of the right and left ankles each were dorsiflexion 5 degrees (normal 20) and plantar flexion 60 degrees (normal 45 degrees) with limitation due to pain, but no appreciable change after repetition.  The examiner’s diagnosis was bilateral moderate pes planus with plantar fasciitis refractory to medical and surgical treatment.  A permanent L3 profile for bilateral plantar fasciitis (s/p left plantar release) was issued on 21 January 2009 with limitations of no running, rucking or marching and use of footgear of comfort as needed.  The commander’s statement referred to the permanent profile and indicated the CI’s condition had become worse.  

At the VA Compensation and Pension (C&P) examination on 13 April 2009, performed 2 months before separation, the CI reported sharp pain in the heel and the arch of the left foot, which occasionally shot up the left leg.  The CI had an antalgic gait and examination of the right foot revealed no evidence of foot or toe deformities, but flatfoot was present.  The weight bearing line was not over or medial to the great toe and there was no pronation or medial bulge of the arch.  The Thompson test (to determine the integrity of the Achilles tendon) was negative and the CI had a relaxed calcaneal stance with 2 degrees valgus.  There was tenderness on palpation of the left heel without any evidence of foot or toe deformities.  Flatfoot was present on the left and the weight bearing line was over or medial to the great toe.  Additionally, there was pronation of the left foot with a medial bulge at the arch.  The Thompson test was negative and the CI had a relaxed calcaneal stance with 5 degrees of valgus.  The examiner’s diagnosis was bilateral plantar fasciitis, left greater than right with residuals of surgery on the left foot.  The VA Rating Decision (VARD) dated 22 January 2010 referred to VA examinations on 5 November 2009 and 3 December 2009, which noted symptoms of pain on both the dorsum and plantar aspects of the left foot and pain of the right foot just in the heel.  Moderate tenderness was present over the medial heel and over the medial and longitudinal arches in the plantar aspect of the left foot. 

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating under an analogous 5299-5276 code (flatfoot, acquired-moderate bilateral) IAW VASRD §4.10, §4.40, §4.45, and §4.59, citing bilateral pes planus with plantar fasciitis.  The VA assigned a 10% rating using an analogous 5099-5020 code (synovitis) based on the VA examinations 1 month before separation and 5 months after separation, citing plantar fasciitis, right foot and a 10% rating using an analogous 5099-5020 citing plantar fasciitis, left foot.  The VA also assigned a 10% rating using 5276 code citing bilateral pes planus.

Board Approach to PEB Consolidated Rating. The PEB combined the bilateral pes planus with plantar fasciitis conditions as a single unfitting condition coded 5299-5276 for moderate disability and rated 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 with plantar fasciitis conditions was presented together above.  In this case, the bilateral condition was addressed in the profile and the bilateral pes planus with plantar fasciitis was implicated by the NARSUM and in the commander’s statement.   Members agreed that each foot condition is separately unfitting, although the left post surgery was worse than the right, but identical coding and ratings could be applicable.  However, the Board members noted that code 5276 at a 10% rating can be applied for either a bilateral or unilateral moderate disability.   The Board majority felt that there was a preponderance of evidence to warrant a 10% rating for each foot.  However, a rating higher than 10% in the absence of objective evidence of marked deformity, pain on manipulation and use accentuated, swelling on use and characteristic callosities, was not applicable for either foot.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board majority recommends a disability rating of 10% for the pes planus with plantar fasciitis, left foot condition, coded 5299-5276 and a disability rating of 10% for the pes planus with plantar fasciitis, right foot condition, coded 5299-5276.  

Contended PEB Conditions:  Bilateral Patellofemoral Syndrome.  The Board’s main charge is to assess the fairness of the PEB’s determination that the contended condition was not unfitting.  The contended condition was not profiled or implicated in the commander’s statement or judged to fail retention standards.  There was no performance-based evidence from the record that the condition significantly interfered with satisfactory duty performance at separation.  After due deliberation, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the contended condition and so no additional disability rating is recommended.  

BOARD FINDINGS:  In the matter of the pes planus with plantar fasciitis, left foot condition, the Board majority recommends a disability rating of 10%, coded 5299-5276 IAW VASRD §4.71a.  In the matter of the pes planus with plantar fasciitis, right foot condition, the Board majority recommends a disability rating of 10%, coded 5299-5276 IAW VASRD §4.71a.  The single voter for dissent recommended no re-characterization and did not elect to submit a minority opinion In the matter of the contended bilateral patellofemoral pain syndrome, 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.  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	
Pes Planus with Plantar Fasciitis, Left Foot	5299-5276	10%	
Pes Planus with Plantar Fasciitis, Right Foot	5299-5276	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

08 DEC 2016

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for 
AR20160017727 (PD201403841)

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, accept the Board’s recommendation to modify the individual’s disability rating to 20% without re-characterization 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