RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00143
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20030402

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Patriot Launching Station Enhanced Operator/Maintainer, medically separated for “bilateral planar fasciitis” with a disability rating of 0%.  

CI CONTENTION:  “Please consider 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 – 20030306	VARD - 20030415	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Plantar Fasciitis	5399-5310	0%	Plantar Fasciitis, Right Foot	5399-5310	10%	20030331	
			Plantar Fasciitis, Left Foot		10%		
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Bilateral PF.  The PEB combined the right and left plantar fasciitis (PF) conditions under a single service disability rating, coded analogously to 5310 (muscle group X injury) and rated 0%.  The approach by the PEB not uncommonly reflected its judgment that the constellation of conditions was unfitting, and there was no need for separate fitness adjudications.  The Board’s initial charge in this case was therefore 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 right and left PF conditions are presented together, with attendant recommendations regarding separate unfitness, and separate rating if indicated. 

According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s bilateral PF condition began in 1998 after running. Bilateral foot X-rays were normal.  There was no surgical indication, and conservative treatment did not result in improvement sufficient to allow unrestricted duty. The MEB forwarded “bilateral plantar fasciitis” for PEB adjudication.  The permanent profile listed bilateral foot pain.  The commander’s statement implicated the CI’s “medical conditions,” with physical limitations of inability to perform heavy lifting, running, jumping, climbing into and out of numerous types of vehicles, as impairing the duty performance.  At the MEB examination on 10 December 2002, 4 months prior to separation, the CI reported pain, cramping, and swelling of both feet and ankles with weight bearing activities.  At the MEB NARSUM examination on 27 January 2003, 2 months prior to separation, the CI reported bilateral foot pain with difficulty walking or standing for prolonged periods.  He reported being unable to perform impact activities such as running and jumping.  The physical examination was reported for the bilateral feet.  There were low arches which diminished with weight bearing. There was moderate to severe tenderness to palpation (TTP) from the heel to the midfoot.  The feet were neurovascularly intact.  

At the 31 March 2003 VA Compensation and Pension (C&P) general medical evaluation, performed 2 days before separation, the CI reported bilateral foot pain graded 7/10, with exacerbation to 10/10 with walking, standing, and running.  He reported no benefit from exercises, or orthotics.  The physical examination showed a normal gait and posture.  There was TTP of the plantar fascia bilaterally with no TTP of the metatarsal joints.  

At the 29 August 2003 VA Compensation and Pension (C&P) feet evaluation, 5 months after separation, the CI reported daily pain in both feet due to PF despite over the counter medications and custom footwear.  He reported the foot pain was aggravated by weight bearing activity.  The VA C&P examiner noted the CI had been given a cane by his VA provider.  The physical examination noted an abnormal gait and abnormal weight bearing.  The same findings were noted for both feet.  There was moderate pain on the plantar aspect of the feet.  There was no swelling or instability, but there was pain with motion of both feet.  There were no skin or vascular changes noted.  There was no pes planus (flatfoot), hallux valgus, hammertoes or other deformity present. Bilateral foot X-rays were normal.  

The Board first considered if the both the right and left PF conditions, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  Both feet were permanently profiled and implicated by the commander’s statement as impairing the CI’s duty performance.  Both feet were imaged and there was no distinction in the record regarding treatment of the PF conditions.  The NARSUM addressed both feet and indicated bilateral PF did not meet retention standards.  The Board concluded there was not a preponderance of evidence in the service records which overcame the presumption that each bundled foot condition was reasonably considered separately unfitting.  The Board then considered its rating recommendation for the right and left PF conditions at separation.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral PF condition 0%, coded analogously to 5310 (group X muscle injuries: the foot and leg).  The VA separately rated the right and left foot PF condition 10% and 10%, respectively, coded analogously to 5310, based on the VA C&P examination 2 days before separation, citing pain and tenderness to the plantar fascia bilaterally.  In response for a request for increase of the PF ratings the VARD dated 31 March 2004 continued the 10% rating, coded 5399-5310 for each foot based upon the VA C&P examination 5 months after separation.  
Board members considered that the objective findings and associated disability for each foot were identical, and agreed that the respective ratings should therefore be the same.  The Board reviewed the rating criteria of 5399-5310 which are subjective, with a 0% rating for `slight,’ 10% rating for `moderate,’ 20% for `moderately severe, and 30% for `severe’ muscle injury.  The Board considered that when coding the disability due to PF analogously as 5310, the discrimination between the `slight’ and `moderate’ characterizations depends on the presence of at least one `cardinal sign or symptom’ of muscle injury specified as “loss of power, weakness, lowered threshold of fatigue, fatigue-pain, impairment of coordination and uncertainty of movement” for `moderate,’ as opposed to none for `slight.’  At all examinations (MEB NARSUM, VA C&P General medical, and VA C&P feet) the CI reported constant foot pain of both feet aggravated by weight bearing activities and examinations noted significant TTP of the plantar fascia of each foot and painful motion of both feet was noted at the VA C&P feet examination.  

Therefore, the Board concluded that based on the presence of the cardinal symptom of fatigue-pain, the disability due to the right and left PF conditions was best described as `moderate’ and not `slight’ and met the 10% rating, but judged it could not be characterized as `moderately severe,’ which by analogy Members judged would require more symptoms and greater objective evidence of foot abnormalities such as observed swelling or evidence of abnormal weight bearing on the feet.  

The Board considered whether a higher rating was supported under other diagnostic code options.  There was no evidence of foot deformity or malunion or nonunion of a tarsal/metatarsal bone of either foot for rating with any other VASRD foot code with higher than a 10% rating available.  The Board considered whether rating under the VASRD code for other foot injuries (5284) provided for a higher rating (§4.7), which has subjective rating criteria also.  However, all Board members agreed that, similar to the rationale under the 5310 code, the PF conditions did not warrant characterization as “moderately severe” other foot injury for the next higher rating. 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 unfitting right PF condition and 10% for the unfitting left PF condition both coded 5399-5310.  

BOARD FINDINGS:  In the matter of the bilateral plantar fasciitis condition, the Board unanimously recommends a disability rating for the bilateral plantar fasciitis conditions as follows: an unfitting right plantar fasciitis condition and an unfitting left plantar fasciitis condition, each rated 10%, both coded 5399-5310 IAW VASRD §4.71a.  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 Foot Plantar Fasciitis	5399-5310	10%	
Right Foot Plantar Fasciitis	5399-5310	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20141222, 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

21 DEC 2016

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for 
XXXXXXXXXXXXXXXXXX, AR20160018489 (PD201500143)

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